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DWQ ID: CORPS ACTION ID:
NATIONWIDE PERMIT REQUESTED (PROVIDE NATIONWIDE PERMIT #) 3
PRE-CONSTRUCTION NOTIFICATION APPLICATION
FOR NATIONWIDE PERMITS THAT REQUIRE:
1. NOTIFICATION TO THE CORPS OF ENGINEERS
2. APPLICATION FOR SECTION 401 CERTIFICATION
3. COORDINATION WITH THE NC DIVISION OF COASTAL MANAGEMENT
SEND THE ORIGINAL AND (1) COPY OF THIS COMPLETED FORM TO THE APPROPRIATE FIELD
OFFICE OF THE CORPS OF ENGINEERS (SEE AGENCY ADDRESSES SHEET). SEVEN (7)
COPIES MUST BE SENT TO THE NC DIVISION OF WATER QUALITY
ATTN• JOHN DORNEY, 4401 REEDY CREEK ROAD, RALEIGH, NC
27607. PLEASE PRINT OR TYPE.
L OWNER'S NAME: NC Department of Transportation, Division 9
2. MAILING ADDRESS: 2125 Cloverdale Ave.
SUBDIVISION NAME
CITY: Winston-Salem STATE: NC ZIP CODE: 27103
PROJECT LOCATION ADDRESS, INCLUDING SUBDIVISION NAME (IF DIFFERENT FROM
MAILING ADDRESS ABOVE):
3. TELEPHONE NUMBER: (HOME) (WORK) 336-761-2613
4. IF APPLICABLE: AGENT'S NAME OR RESPONSIBLE CORPORATE OFFICIAL, ADDRESS,
PHONE NUMBER:
Diane Hampton. PE, DEO
2125 Cloverdale Ave.
Winston-Salem. NC 27103
5. LOCATION OF WORK (PROVIDE A MAP, PREFERABLY A COPY OF USGS TOPOGRAPHIC MAP
OR AERIAL PHOTOGRAPHY WITH SCALE):
COUNTY: For h - NEAREST TOWN: Kernersville
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ECT.) SR 2016 Pumpkin Ride
Rd. Bridge 70
6. IMPACTED OR NEAREST STREAM/RIVER: East Belews Creek RIVER BASIN: Roanoke
7. (a) IS PROJECT LOCATED NEAR WATER CLASSIFIED AS TROUT, TIDAL SALTWATER, (SA),
HIGH QUALITY WATERS (HQW), OUTSTANDING RESOURCE WATERS (ORW), WATER
SUPPLY (WS-1 OR WS-II)? YES ? NO ® IF YES, EXPLAIN:
(b) IS THE PROJECT LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL
MANAGEMENT AREA OF ENVIRONMENTAL CONCERN (AEC)? YES ? NO
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(c) IF THE PROJECT IS LOCATED WITHIN A COASTAL COUNTY (SEE PAGE 7 FOR LIST OF
COASTAL COUNTIES), WHAT IS THE LAND USE PLAN (LUP) DESIGNATION? no
10,
8. (a) HAVE ANY SECTION 404 PERMITS BEEN PREVIOUSLY REQUESTED FOR USE ON THIS
PROJECT? YES ? NO ® IF YES, PROVIDE ACTION I.D. NUMBER OF PREVIOUS PERMIT AND
ANY ADDITIONAL INFORMATION (INCLUDE PHOTOCOPY OF 401 CERTIFICATION):
(b) ARE ADDITIONAL PERMIT REQUESTS EXPECTED FOR THIS PROPERTY IN THE FUTURE?
YES ? NO ® IF YES, DESCRIBE ANTICIPATED WORK:
9. (a) ESTIMATED TOTAL NUMBERS OF ACRES IN TRACT OF LAND:.OI
(b) ESTIMATED TOTAL NUMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE:
none
10. (a) NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING: 0 EXCAVATION: 0
FLOODING: 0 OTHER : 0
DRAINAGE : 0 TOTAL ACRES TO BE IMPACTED: none
(b) (1) STREAM CHANNEL TO BE IMPACTED BY THE PROPOSED PROJECT (IF RELOCATED,
PROVIDE DISTANCE BOTH BEFORE AND AFTER RELOCATION: N/A
LENGTH BEFORE: FT AFTER: FT
WIDTH BEFORE (based on nomial high water contours): FT
AVERAGE DEPTH BEFORE: FT AFTER: FT
(b) (2) STREAM CHANNEL IMPACTS WILL RESULT FROM: (CHECK ALL THAT APPLY)
OPEN CHANNEL RELOCATION: PLACEMENT OF PIPE IN CHANNEL: :
CHANNEL EXCAVATION: CONSTRUCTION OF A DAM/FLOODING:
OTHER: very minor impact from replacement of piles for new bridge, less than 30 feet.
11. IF CONSTRUCTION OF A POND IS PROPOSED, WHAT IS THE SIZE OF THE WATERSHED
DRAINING TO THE POND? N/A WHAT IS THE EXPECTED POND SURFACE AREA? N/A
12. DESCRIPTION OF PROPOSED WORK INCLUDING DISCUSSION OF TYPE OF MECHANICAL
EQUIPMENT TO BE USED? (ATTACH PLANS; 81/2 BY 11 DRAWINGS ONLY)
To replace old steel I-beam bridge with new cored slab bridge.
13. PURPOSE OF PROPOSED WORK: To replace old bridge with new on same location.
14. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS (INCLUDE ANY MEASURES TAKEN TO MI EVIIZE WETLAND IMPACTS)
N/A
15. YOU ARE REQUIRED TO CONTACT THE US FISH AND WILDLIFE SERVICE AND/OR
NATIONAL MARINE FISHERIES SERVICE REGARDING THE PRESENCE OF ANY FEDERALLY
LISTED OR PROPOSED FOR LISTING ENDANGERED OR THREATENED SPECIES OR CRITICAL
HABITAT IN THE PERMIT AREA THAT MAY BE AFFECTED BY THE PROPOSED PROJECT.
DATE CONTACTED: 1/10/01.
16. YOU ARE REQUIRED TO CONTACT THE STATE HISTORIC PRESERVATION OFFICER
(SHPO) REGARDING THE PRESENCE OF HISTORIC PROPERTIES IN THE PERMIT AREA
WHICH MAY BE AFFECTED BY THE PROPOSED PROJECT. DATE CONTACTED 1/10/01.

17. DOES THE PROJECT INVOLVE AN EXPENDITURE OF PUBLIC FUNDS OT THE USE OF PUBLIC
(STATE) LAND? YES ® NO E] (IF NO, GO TO 16)
(a) IF YES, DOES THE PROJECT REQUIRE PREPARATION OF AN ENVIRONMENTAL
DOCUMENT PURSUANT TO THE REQUIREMENTS OF THE NORTH CAROLINA
ENVIRONMENTAL POLICY ACT? YES ? NO
(b) IF YES, HAS THE DOCUMENT BEEN REVIEWED THROUGH THE NORTH CAROLINA
DEPARTMENT OF ADMINISTRATION STATE CLEARINGHOUSE YES ? NO ? N/A
IF ANSWER 17b IS YES, THEN SUBMIT APPROPRIATE DOCUMENTATION FROM THE STATE
CLEARINGHOUSE WITH THE NORTH CAROLINA ENVIRONMENTAL POLICY ACT.
QUESTIONS REGARDING THE STATE CLEARINGHOUSE REVIEW PROCESS SHOULD BE
DIRECTED TO MS. CHRYS BAGGETT, DIRECTOR STATE CLEARINGHOUSE, NORTH
CAROLINA DEPARTMENT OF ADMINISTRATION, 116 WEST JONES STREET, RALEIGH,
NORTH CAROLINA 27603-8003, TELEPHONE [phone].
18. THE FOLLOWING ITEMS SHOULD BE INCLUDED WITH THIS APPLICATION IF PROPOSED
ACTIVITY INVOLVES THE DISCHARGE OF EXCAVATED OF FILL MATERIAL INTO
WETLANDS:
(a) WETLAND DELINEATION MAP SHOWING ALL WETLANDS, STREAMS, LAKES, AND
PONDS ON THE PROPERTY (FOR NATIONWIDE PERMIT NUMBERS 14, 18, 21, 26, 29, AND 38).
ALL STREAM (INTERMITTENT AND PERMANENT) ON THE PROPERTY MUST BE SHOWN ON
THE MAP. MAP SCALES SHOULD BE 1 INCH EQUALS 50 FEET OF 1 INCH EQUALS 100 FEET
OF THEIR EQUIVALENT.
(b) IF AVAILABLE, REPRESENTATIVE PHOTOGRAPH OF WETLANDS TO BE IMPACTED BY
PRODUCT.
(c) IF DELINEATION WAS PERFORMED BY A CONSULTANT, INCLUDE ALL DATA SHEETS
RELEVANT TO THE PLACEMENT OF THE DELINEATION LINE.
(d) ATTACH A COPY OF THE STORMWATER MANAGEMENT PLAN IF REQUIRED.
(e) WHAT IS LAND USE OF SURROUNDING PROPERTY?
(f) IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL?
SIGNED AND DATED AGENT AUTHORIZATION LETTER, IF APPLICABLE.
NOTE: WETLANDS OR WATERS OF THE US MAY NOT BE IMPACTED PRIOR TO:
1. ISSUANCE OF A SECTION 404 CORPS OF ENGINEERS PERMIT,
2. EITHER THE ISSUANCE OR WAIVER OF A 401 DIVISION OF WATER QUALITY
CERTIFICATION, AND
3. (IN THE TWENTY COASTAL COUNTIES ONLY), A LETTER FROM THE NORTH
CAROLINA DIVISION OF COASTAL MANAGEMENT STATING THE PROPOSED
ACTIVITY IS CONSISTENT WITH THE NORTH CAROLINA COASTAL MANAGEMENT
OWNER'S/AGENT'S SIGNATURE DA
(AGENT'S SIGNATURE VALID ONLY
IF AUTHORIZATION LETTER FROM
THE OWNER IS PROVIDED).
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DWQ ID: CORPS ACTION ID:
NATIONWIDE PERMIT REQUESTED (PROVIDE NATIONWIDE PERMIT #) 3
PRE-CONSTRUCTION NOTIFICATION APPLICATION
FOR NATIONWIDE PERMITS THAT REQUIRE:
1. NOTIFICATION TO THE CORPS OF ENGINEERS
2. APPLICATION FOR SECTION 401 CERTIFICATION
3. COORDINATION WITH THE NC DIVISION OF COASTAL MANAGEMENT
SEND THE ORIGINAL AND (1) COPY OF THIS COMPLETED FORM TO THE APPROPRIATE FIELD
OFFICE OF THE CORPS OF ENGINEERS (SEE AGENCY ADDRESSES SHEET). SEVEN (7)
COPIES MUST BE SENT TO THE NC DIVISION OF WATER QUALITY,
ATTN: JOHN DORNEY, 4401 REEDY CREEK ROAD, RALEIGH, NC
27607. PLEASE PRINT OR TYPE.
1. OWNER'S NAME: NC Department of Transportation Division 9
2. MAILING ADDRESS: 2125 Cloverdale Ave.
SUBDIVISION NAME
CITY: Winston-Salem STATE: NC ZIP CODE: 27103
PROJECT LOCATION ADDRESS, INCLUDING SUBDIVISION NAME (IF DIFFERENT FROM
MAILING ADDRESS ABOVE):
3. TELEPHONE NUMBER: (HOME) (WORK) 336-761-2613
4. IF APPLICABLE: AGENT'S NAME OR RESPONSIBLE CORPORATE OFFICIAL, ADDRESS,
PHONE NUMBER:
Diane Hampton. PE. DEO
2125 Cloverdale Ave.
Winston-Salem- NC 27103
5. LOCATION OF WORK (PROVIDE A MAP, PREFERABLY A COPY OF USGS TOPOGRAPHIC MAP
OR AERIAL PHOTOGRAPHY WITH SCALE):
COUNTY: For h - NEAREST TOWN: Kernersville
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ECT.) SR 2016 Pumpkin Ridge
Rd. Bridge 70
6. IMPACTED OR NEAREST STREAM/RIVER: East Belews Creek RIVER BASIN: Roanoke
7. (a) IS PROJECT LOCATED NEAR WATER CLASSIFIED AS TROUT, TIDAL SALTWATER, (SA),
HIGH QUALITY WATERS (HQW), OUTSTANDING RESOURCE WATERS (ORW), WATER
SUPPLY (WS-1 OR WS-II)? YES ? NO ® IF YES, EXPLAIN: m D
(b) IS THE PROJECT LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL rn
MANAGEMENT AREA OF ENVIRONMENTAL CONCERN (AEC)? YES El NO ® C

(c) IF THE PROJECT IS LOCATED WITHIN A COASTAL COUNTY (SEE PAGE 7 FOR LIST OF * 1
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COASTAL COUNTIES), WHAT IS THE LAND USE PLAN (LUP) DESIGNATION? no
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8. (a) HAVE ANY SECTION 404 PERMITS BEEN PREVIOUSLY REQUESTED FOR USE ON THIS
PROJECT? YES ? NO ® IF YES, PROVIDE ACTION I.D. NUMBER OF PREVIOUS PERMIT AND
ANY ADDITIONAL; INFORMATION (INCLUDE PHOTOCOPY OF 401 CERTIFICATION):
(b) ARE ADDITIONAL PERMIT REQUESTS EXPECTED FOR THIS PROPERTY IN THE FUTURE?
YES ? NO ® IF YES, DESCRIBE ANTICIPATED WORK:
9. (a) ESTIMATED TOTAL NUMBERS OF ACRES IN TRACT OF LAND:.O 1
(b) ESTIMATED TOTAL NUMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE:
none
10. (a) NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING: 0 EXCAVATION: 0
FLOODING: 0 OTHER : 0
DRAINAGE : 0 TOTAL ACRES TO BE IMPACTED: none
(b) (1) STREAM CHANNEL TO BE IMPACTED BY THE PROPOSED PROJECT (IF RELOCATED,
PROVIDE DISTANCE BOTH BEFORE AND AFTER RELOCATION: N/A
LENGTH BEFORE: FT AFTER: FT
WIDTH BEFORE (based on nornial high water contours): FT
AVERAGE DEPTH BEFORE: FT AFTER: FT
(b) (2) STREAM CHANNEL IMPACTS WILL RESULT FROM: (CHECK ALL THAT APPLY)
OPEN CHANNEL RELOCATION: PLACEMENT OF PIPE IN CHANNEL:
CHANNEL EXCAVATION: CONSTRUCTION OF A DAMIFLOODING:
OTHER: very minor impact from replacement of piles for new bridge, less than 30 feet.
11. IF CONSTRUCTION OF A POND IS PROPOSED, WHAT IS THE SIZE OF THE WATERSHED
DRAINING TO THE POND? N/A WHAT IS THE EXPECTED POND SURFACE AREA? N/A
12. DESCRIPTION OF PROPOSED WORK INCLUDING DISCUSSION OF TYPE OF MECHANICAL
EQUIPMENT TO BE USED? (ATTACH PLANS; 81/2 BY 11 DRAWINGS ONLY)
To replace old steel I-beam bridge with new cored slab bridge.
13. PURPOSE OF PROPOSED WORK: To replace old bridge with new on same location.
14. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS (INCLUDE ANY MEASURES TAKEN TO MINIMIZE WETLAND IMPACTS)
N/A
15. YOU ARE REQUIRED TO CONTACT THE US FISH AND WILDLIFE SERVICE AND/OR
NATIONAL MARINE FISHERIES SERVICE REGARDING THE PRESENCE OF ANY FEDERALLY
LISTED OR PROPOSED FOR LISTING ENDANGERED OR THREATENED SPECIES OR CRITICAL
HABITAT IN THE PERMIT AREA THAT MAY BE AFFECTED BY THE PROPOSED PROJECT.
DATE CONTACTED: 1/10/01.
16. YOU ARE REQUIRED TO CONTACT THE STATE HISTORIC PRESERVATION OFFICER
(SHPO) REGARDING THE PRESENCE OF HISTORIC PROPERTIES IN THE PERMIT AREA
WHICH MAY BE AFFECTED BY THE PROPOSED PROJECT. DATE CONTACTED 1/10/01.
v -A
17. DOES THE PROJECT INVOLVE AN EXPENDITURE OF PUBLIC FUNDS OT THE USE OF PUBLIC
(STATE) LAND? YES ® NO ? (IF NO, GO TO 16)
(a) IF YES, DOES THE PROJECT REQUIRE PREPARATION OF AN ENVIRONMENTAL
DOCUMENT PURSUANT TO THE REQUIREMENTS OF THE NORTH CAROLINA
ENVIRONMENTAL POLICY ACT? YES ? NO
(b) IF YES, HAS THE DOCUMENT BEEN REVIEWED THROUGH THE NORTH CAROLINA
DEPARTMENT OF ADMINISTRATION STATE CLEARINGHOUSE YES ? NO ? N/A
IF ANSWER 17b IS YES, THEN SUBMIT APPROPRIATE DOCUMENTATION FROM THE STATE
CLEARINGHOUSE WITH THE NORTH CAROLINA ENVIRONMENTAL POLICY ACT.
QUESTIONS REGARDING THE STATE CLEARINGHOUSE REVIEW PROCESS SHOULD BE
DIRECTED TO MS. CHRYS BAGGETT, DIRECTOR STATE CLEARINGHOUSE, NORTH
CAROLINA DEPARTMENT OF ADMINISTRATION, 116 WEST JONES STREET, RALEIGH,
NORTH CAROLINA 27603-8003, TELEPHONE [phone].
18. THE FOLLOWING ITEMS SHOULD BE INCLUDED WITH THIS APPLICATION IF PROPOSED
ACTIVITY INVOLVES THE DISCHARGE OF EXCAVATED OF FILL MATERIAL INTO
WETLANDS:
(a) WETLAND DELINEATION MAP SHOWING ALL WETLANDS, STREAMS, LAKES, AND
PONDS ON THE PROPERTY (FOR NATIONWIDE PERMIT NUMBERS 14, 18, 21, 26, 29, AND 38).
ALL STREAM (INTERMITTENT AND PERMANENT) ON THE PROPERTY MUST BE SHOWN ON
THE MAP. MAP SCALES SHOULD BE 1 INCH EQUALS 50 FEET OF 1 INCH EQUALS 100 FEET
OF THEIR EQUIVALENT.
(b) IF AVAILABLE, REPRESENTATIVE PHOTOGRAPH OF WETLANDS TO BE IMPACTED BY
PRODUCT.
(c) IF DELINEATION WAS PERFORMED BY A CONSULTANT, INCLUDE ALL DATA SHEETS
RELEVANT TO THE PLACEMENT OF THE DELINEATION LINE.
(d) ATTACH A COPY OF THE STORMWATER MANAGEMENT PLAN IF REQUIRED.
(e) WHAT IS LAND USE OF SURROUNDING PROPERTY?
(f) IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL?
SIGNED AND DATED AGENT AUTHORIZATION LETTER IF APPLICABLE.
NOTE: WETLANDS OR WATERS OF THE US MAY NOT BE IMPACTED PRIOR TO:
I. ISSUANCE OF A SECTION 404 CORPS OF ENGINEERS PERMIT,
2. EITHER THE ISSUANCE OR WAIVER OF A 401 DIVISION OF WATER QUALITY
CERTIFICATION, AND
3. (IN THE TWENTY COASTAL COUNTIES ONLY), A LETTER FROM THE NORTH
CAROLINA DIVISION OF COASTAL MANAGEMENT STATING THE PROPOSED
ACTIVITY IS CONSISTENT WITH THE NORTH CAROLINA COASTAL MANAGEMENT
PRO
OWNER'S/AGENT'S SIGNATURE DA
(AGENT'S SIGNATURE VALID ONLY
IF AUTHORIZATION LETTER FROM
THE OWNER IS PROVIDED).
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Keuffel & Esser Company PLATE 1, PLAN-PP LATE 1, PLAN-PROFILE 487004 Made in U.S.A - ~D~C