20041150 Ver 2_401 Application_20190913

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P.O. Box 10 9 Bethama, NG 1rulu-uuIu 0 ssd-uzz-4uuu • rax aao-acc- i ioc

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Office Use Only:
1 Corps action ID no.
DWQ project no,
Form Version 1.4 January 2009
Pre -Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1 a. Type(s) of approval sought from the Corps: Section 404 Permit ❑ Section 10 Permit
1b. Specify Nationwide Permit (NWP) number: or General Permit (GP) number:
1c. Has the NWP or GP number been verified by the Corps? ❑ Yes No
1d. Type(s) of approval sought from the DWQ (check all that apply):
401 Water Quality Certification — Regular
❑ Non -404 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorization
le. Is this notification solely for the record For the record only for DWQ For the record only for Corps Permit:
because written approval is not required? 401 Certification:
❑ Yes0 No Yes ❑ No
1f. Is payment into a mitigation bank or in -lieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from
mitigation bank ❑ Yes No
or in -lieu fee program.
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below. ❑ Yes No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ❑ Yes �,� No
2. Project Information
2a. Name of project: 414{}��3C�V1�lON
2b. County:
2c. Nearest municipality /town:
2d. Subdivision name: KaGI,
2e. NCDOT only, T.I.P. or state project no:
3. Owner Information
3a. Name(s) on Recorded Deed:
3b. Deed Book and Page No.
> G1p{C &O33(O"t
3c. Responsible,Party (for LLC if
applicable):
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. 0 • �o X 10 a ( 1 Cq,vSa� A�
3d. Street address:
3e. City, state, zip:
VET-Axo 1A► N -C,. 27010 W!0'MM-fAL&4,NC ZZ1040
3f. Telephone no.:
33(f � Q22 . 460 0
3g. Fax no.:
334. 42Z.1i6L
3h. Email address:
MW%i.ti,, ILD6@TiL%Ab ZV_#C.OM a_TtRAm Yni
Page 1 of 10
PCN Form —Version 1.4 January 2009
4F -T -

4. Applicant Information (if different from owner)
4a. Applicant is:
[] Agent ❑ Other, specify:
4b. Name:
4c. Business name
(if applicable):
4d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. Agent/Consultant Information (if applicable)
ALA
5a. Name:
5b. Business name
(if applicable):
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:
Page 2 of 10

B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (ta)rPIN or parcel ID): -
G►aG?
1 b. Site coordinates (in decimal degrees): I Latitude:
1c. Property size: � 2 � $ � � �
acres Longitude: LJ� R
2. Surface Waters
2a. Name of nearest body of water to proposed project:
2b. Water Quality Classification of nearest receiving water: AA LLL_
2c. River basin:
3. Project Description °favl� _
3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application: IZC_,• 51J �DiIv11rIQ.•i / 11cED � T
R05. -r4¢ Ews
3b. List the total estimated acreage of all existing wetlands on the property: C. '5 ,,ate
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
3d. Explain the purpose of the proposed project: 4=JZA0="&Ir4dq 1�L.E[�yltzl"S -gyp ec
Aez*$ Or-TI� paa?dm_.IZ-M7 i=041K 4=eAA FILI, („µ„QE, rt ao.
3e. Describe the overall project in detail in I di the type of a Li ment to be sed:I M.ST. 3G cww iMT AEA))WAU,. Zfr
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4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property / 'Yes ❑ No ❑ Unknown
project(including all priorphases) in thepast? Comments:
4b. If the Corps made the jurisdictional determination, what type
of determination was made? a ❑ Preliminary ❑ Final
4c. If yes, who delineated the jurisdictional areas? Agency/Consultant Com
Name (if known): pan
y:
Other: 5VetLL.V 4 L -9 L
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5. Project History
5a. Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past? ErYes ❑ No ❑ Unknown
5b. If yes, explain in detail according to "help file" instructions.
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6. Future Project Plans
6a. Is this a phased project?
6b. If yes, explain.
❑ Yes PIN -0
Page 3 of 10
PCN Form -Version 1.4 January 2009

C. Proposed Impacts Inventory
a/A
I. Impacts Summary
or intermittent stream
sites impacted.
impacts (including temporary
impacts) proposed on the site, then complete this
1 a. Which sections were completed below for your project (check that
3b.
Type of impact
Yp p
3c.
Stream name
all apply):
Wetlands ❑Streams —tributaries ❑ Buffers
Permanent (P) or
2• Wetland Impacts
❑ Open Waters
❑ Pond Construction
If there are wetland
2a.
impacts proposed on the site, then complete this question
for each wetland
(feet) feet)
S2 -
2b.
2c.
area impacted.
Choose one
Wetland impact
number
Type of impact
Type of wetland
2d.
Forested
2e•
Type of jurisdiction
2f
Permanent (P) or
Tem ora T
Choose one
Corps (404,10) or
Area of
impact
W1 -
3i. Comments:
DWQ (401, other)
(acres)
W2 If
Choose one 4i ISL•T
t
Choose one A16WITI&I ..
t
Yes/No /�
404
-
W3 Q
Choose oneDim
Choose
Choose one II
Yes/No -
4 A
.001
Utz
W4
one fm -L-
u
Choose one to
Yes/No
�p
-
Choose one f�L�
Ll NEI
Choose one
p
W5 -
Choose one
Choose one
Yes/No
LA d 14c
e9 G
W6 -
Choose one
Choose one
Yes/No
Yes/No
2h. Comments:
2g. Total Wetland Impacts:
, pC�Q
3. Stream Impacts
a/A
If there are perennial
question for all stream
or intermittent stream
sites impacted.
impacts (including temporary
impacts) proposed on the site, then complete this
3a.
Stream impact
number
3b.
Type of impact
Yp p
3c.
Stream name
3d. 3e. 3f. ° 3g.
Perennial (PER) or Type of
Permanent (P) or
Average Impact
intermittent (INT)?
( ) jurisdiction stream length
Temporary (T)
width (linear
S1 -
Choose one
(feet) feet)
S2 -
Choose one
S3 -
Choose one
S4 -
Choose one
S5 -
Choose one
S6 -
Choose one
3i. Comments:
3h. Total stream and tributary impacts
Page 4 of 10
PCN Form — Version 1.4 January 2009

4. Open Water Impacts palA
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individual) list all open water impacts below.
4a. 4b.
Open water Name of waterbody 4c. 4d.
4e.
impact number (if applicable)
Permanent (P) or Type of impact Waterbody Area of impact (acres)
Temporary T type
01 -
Choose one
02 Choose
Choose one
03 Choose
-
Choose one
04 Choose
-
Choose one
4g. Comments:
5. Pond or Lake Construction A//ti
If pond or lake construction proposed then
5a. 5b.
Pond ID number Proposed use or.
Purpose of pond
P1 Choose one
P2 Choose one
5f. Total:
59. Comments:
Choose
4f. Total open water impacts
nom tete the chart below.
5c. 5d.
e.
Wetland Impacts (acres) Stream Impacts (feet) 5U land
p
Flooded Filled Excavated Flooded Filled Excavated (acres)
5h. Is a dam high hazard permit required?Yes
5i. Expected pond surface area (acres): ❑ E] No If yes, permit ID no:
5j. Size of pond watershed (acres):
5k. Method of construction:
6. Buffer Impacts (for DWQ) 14, A
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If any impacts require mitigation, then You MUST fill out Section D of this form.
6a. Project is in which protected basin? [] Neuse (] Tar -Pamlico ❑ Catawba [] Randleman ❑ Other:
6b. 6c. 6d.
Buffer Impact Reason for impact 6e• 6f. gg
number — Stream name Buffer Zone 1
Permanent (P) or Zone 2
mitigation impact impact
Tem ora required? (square (square
61
B2 _
Yes/No
_
Yes/No
_
Yes/No
-
jB5
Yes/No
-
Yes/No
Yes/No
6i. Comments:
6h. Total Buffer Impacts:
Page 5 of 10

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designinE project.
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1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
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2. Com
for lm
to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State?
2b. If yes, mitigation is required by (check all that apply):
2c. If yes, which mitigation option will be used for this
Project?
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter)
3c. Comments:
❑ Yes ❑ No
❑ DWQ ❑ Corps
❑ Mitigation bank
❑ Payment to in -lieu fee program
❑ Permittee Responsible Mitigation
Type: Choose one Quantity:
Type: Choose one Quantity:
Type: Choose one I Quantity:
4. Complete if Makinn a Pa ment to In -lieu Fee Pro ram
4a. Approval letter from in -lieu fee program is attached.
❑ Yes
4b. Stream mitigation requested:
linear feet
4c. If using stream mitigation, stream temperature: Choose one
4d. Buffer mitigation requested (DWQ only):
square feet
4e. Riparian wetland mitigation requested:
acres
4f. Non -riparian wetland mitigation requested:
4g. Coastal (tidal) wetland mitigation requested: acres
acres
4h. Comments:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 6 of 10
PCN Form – Version 1.4 January 2009

r
6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ NIA
6a. Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation? ❑ Yes ❑ No
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.
6c. 6d.
Zone Reason for impact Total impact 6e.
P Multiplier Required mitigation
(square feet)
(square feet)
Zone 1
3 (2 for Catawba)
Zone 2
1.5
6f. Total buffer mitigation required:
6g. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in -lieu fee fund).
6h. Comments:
Page 7 of 10

r
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1a. Does the project include or is it adjacent to protected riparian buffers identified
within one of the NC Riparian Buffer Protection Rules? ❑ Yes No
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
❑ Yes [] No
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project?
2b. Does this project require a Stormwater Management Plan?
No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why: �UE'iZ7 Y�N-t^ V►,�
No
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2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
2e. Who will be responsible for the review of the Stormwater Management Plan?
3. Certified Local Government Stormwater Review
In
slurisdiction is
3b. Which of the following locally -implemented stormwater management programs
apply (check all that apply):
3c. Has the approved Stormwater Management Plan with proof of approval been
attached?
4.
4a. Which of the following state -implemented stormwater management programs apply
(check all that apply):
4b. Has the approved Stormwater Management Plan with proof of approval been
attached?
5. DWQ 401 Unit Stormwater Review
5a. Does the.Stormwater Management Plan meet the appropriate requirements?
5b. Have all of the 401 Unit submittal requirements been met?
❑ Phase II
❑ NSW
[] USMP
❑ Water Supply Watershed
[TOther: ��=
❑ Yes ❑ No
❑Coastal counties
❑HQW
❑ORW
El Session Law 2006-246
❑Other:
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes [] No
Page 8 of 10
PCN Form — Version 1.4 January 2009

,r
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1 a. Does the project involve an expenditure of public (federal/state/local) funds or the ,,
�
use of public (federal/state) land? ❑ Yes 2 No
1 b. If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State
(North Carolina) Environmental Policy Act (NEPA/SEPA)? El Yes El No
1c. If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
letter.) ❑ Yes ❑ No
Comments:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 2H.0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards, E:1Yes [Jf
or Riparian Buffer Rules (15A NCAC 2B .0200)? No
F2b. Is this an after -the -fact permit application? /
❑ Yes 2 No
2c. If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in
additional development, which could impact nearby downstream water quality? ❑ Yes ZNo
3b. If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short narrative description.
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4. Sewage Disposal (DWQ Requirement)
4a. Clearly detail the ultimate treatment methods and disposition (non -discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility.
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Page 9 of 10
PCN Form - Version 1.4 January 2009

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S. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
habitat? ❑ Yes D/
L9 No
5b. Have you checked with the USFWS concerning Endangered Species Act
impacts? El Yes
No
5c. If yes, indicate the USFWS Field Office you have contacted.
5d. What data sources didou use to determine whether you
Habitat? (J -5 FlS�r site would impact Endangered Species or Designated Critical
�W(1-13WVMWc�'t3.5 tore:
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat?
❑ Yes 20
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
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7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation
status (e.g., National Historic Trust designation or properties significant in ❑ Yes ® No
North Carolina history and archaeology)? /I T
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA -designated 100 -year floodplain?
DY
es
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination?
Applicant/Agent's Printed Name
Applicant/Agent's Sign re
(Agent's signature is valid only if an authorization
letter from the applicant is orovided
Page 10 of 10
Date

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