20011171 Ver 1_Complete File_20010802

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Mtcnael r. tasley, t7overnor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
> y Gregory J. Thorpe, Ph.D.
Acting Director
Division of Water Quality
August 21, 2001
DWQ # 011171
Polk County
Mr. J.D. Metcalfe, NCDOT
Bridge Maintenance Engineer
Division 14
Post Office Box 77
Whittier, NC 28789
Dear Mr. Metcalfe:
On August 2, 2001 the Division of Water Quality (DWQ) was notified by receipt of your applications regarding your plan to fill
streams for the purpose of replace Bridge No 136 on SR 1313 in Polk County. Approval from DWQ is required to disturb these
streams. Please provide seven copies of the following information and refer to the DWQ # listed above in your reply. In particular as
described in 15A NCAC 2B .0502, we will require you to locate all streams and ponds on the property on a site plan which also shows
all other related stream impacts. Also please let us know which Nationwide Permit the Corps of Engineers has decided can be used for
this project. Please show these on maps of suitable scale (for instance 1" = 100 feet) so we can begin to determine your projects'
compliance with 15A NCAC 2H .0500.
Please call Cynthia Van Der Wiele at [phone] if you have any questions or would require copies of our rules or
irocedural materials. This project will remain on hold as incomplete in accordance with 15A NCAC 2H .0505(c). The processing time
or this application will begin when this information is received. If we do not hear from you by writing within three (3) weeks we will
assume you no longer want to pursue the project and will consider it withdrawn.
:c: Asheville DWQ Regional Office
Asheville Corps of Engineers
File Copy
Central Files -
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etlands/40
1 Unit 1650 Mail Service Center Raleigh, NC 27699-1650 Ph: [phone] Fax: [phone] Customer Sr
1 800 623
vvr+t??Q micnaei r. easiey, tmovernor
,-z\z 0A William G. Ross Jr., Secretary
`O North Carolina Department of Environment and Natural Resources
j Gregory J. Thorpe, Ph.D.
Acting Director
a Y Division of Water Quality
August 21, 2001
DWQ # 011171
Polk County
Mr. J.D. Metcalfe, NCDOT
Bridge Maintenance Engineer
Division 14
Post Office Box 77
Whittier, NC 28789
Dear Mr. Metcalfe:
On August 2, 2001 the Division of Water Quality (DWQ) was notified by receipt of your applications regarding your plan to fill
streams for the purpose of replace Bridge No 136 on SR 1313 in Polk County. Approval from DWQ is required to disturb these
streams. Please provide seven copies of the following information and refer to the DWQ # listed above in your reply. In particular as
described in 15A NCAC 2B .0502, we will require you to locate all streams and ponds on the property on a site plan which also shows
all other related stream impacts. Also please let us know which Nationwide Permit the Corps of Engineers has decided can be used for
this project. Please show these on maps of suitable scale (for instance 1" = 100 feet) so we can begin to determine your projects'
compliance with 15A NCAC 2H .0500.
Please call Cynthia Van Der Wiele at [phone] if you have any questions or would require copies of our rules or
procedural materials. This project will remain on hold as incomplete in accordance with 15A NCAC 2H .0505(c). The processing time
for this application will begin when this information is received. If we do not hear from you by writing within three (3) weeks we will
assume you no longer want to pursue the project and will consider it withdrawn.
Si c el ,
R. orney
Cc: Asheville DWQ Regional Office
Asheville Corps of Engineers
File Copy
Central Files
Wetlands/401 Unit 1650 Mail Service Center Raleigh, NC 27699-1650 Ph: [phone] Fax: [phone]
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Customer Sr
1 800 623 J
WAIF Michael F. Easley, Governor
\O?? RQG William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
r - Gregory J. Thorpe, Ph.D.
> Acting Director
-? Division of Water Quality
October 25, 2001
Polk County
DWQ Project No. 011171
Bridge No. 136 on SR 1313
APPROVAL of 401 Water Quality Certification with Additional Conditions
Mr. J.D. Metcalf, Bridge, Maintenance Engineer
NCDOT Division 14
P.O. Box 77
Whittier, NC 28789
Dear Mr. Metcalf:
You have our approval, in accordance with the attached conditions and those listed below, to impact
50 linear feet of Canal Creek in order to replace Bridge No. 136 on SR 1313 with a corrugated metal
pipe arch in Polk County. The project should be constructed in accordance with your application
dated July 18, 2001 and additional information dated September 13, 2001. After reviewing your
application, we have decided that this fill is covered by General Water Quality Certification No. 3289
corresponding to the U.S. Army Corps of Engineers Nationwide Permit Number 14. In addition, you
should acquire any other federal, state or local permits before you proceed with your project including
(but not limited to) Sediment and Erosion Control, Non-Discharge and Water Supply Watershed
regulations. This approval will expire with the accompanying 404 permit unless otherwise specified
in the Water Quality Certification.
This approval is only valid for the purpose and design that you described in your application except as
modified below. If you change your project, you must notify us in writing, and send us a new,
application. If the property is sold, the new owner must be given a copy of this Certification and
approval letter and is thereby responsible for complying with all conditions. If total wetland fills for
this project (now or in the future) exceed one acre or stream impacts exceed 150 linear feet,
compensatory mitigation may be required as described in 15A NCAC.211.0506 (h) (6) and (7). For
this approval to be valid, you must follow the conditions listed in the attached certification and any
additional conditions listed below.
-1.- Sedimentation and erosion control must be implemented prior to any ground-disturbing activities-
to minimize impacts to downstream aquatic resources. Temporary or permanent herbaceous
vegetation shall be planted on all bare soil within 10 days of ground-disturbing activities to
provide long term erosion control.
2. All "structures required for this project shall be installed in such a manner that the original stream
profiles are not altered (i.e. 'the depth of the channel must not be reduced by a -widening of the
streambed). Existing stream dimensions are to be maintained above and below locations of
culvert extensions. The pipe arch shall be installed one foot below the stream to allow for fish
and other wildlife movement.
3. All work shall be performed during low flow conditions.
North Carolina Division of Water Quality, 401 Wetlands Certification Unit,
1650 Mail Service Center, Raleigh, NC 27699-1650 (Mailing Address)
2321 Crabtree Blvd., Raleigh, NC 27604-2260 (Location)
919-733-1786 (phone), 919-733-6893 (fax), httpJ/h2o.enr.state.nc.ustncwetiands/
4. All mechanized equipment operated near surface waters must be regularly inspected and
maintained to prevent contamination of stream waters from fuels, lubricants, hydraulic fluids, or
other toxic materials.
5. The presence of equipment in the channels must be minimized. Under no circumstances shall
rock, sand or other materials be dredged from the wetted stream channel under authorization of
this permit, except in the immediate vicinity of the culverts.
6. Existing vegetated buffers shall not be mowed in order to utilize it for storm water sheet flow.
7. Rip-rap must be limited to the stream bank below the high water mark, and vegetation must be
used for stabilization above high water.
Upon completion of the project, the NCDOT shall complete and return the enclosed
"Certificate of Completion" form to notify NCDWQ when all work included in the §401
Certification has been completed. The responsible party shall complete the attached form
and return it to the 401/Wetlands Unit of the NC Division of Water Quality upon
completion of the project.
If you do not accept any of the conditions of this certification, you may ask for an adjudicatory
hearing. You must act within 60 days of the date that you receive this letter. To ask for a hearing,
send a written petition that conforms to Chapter 150B of the North Carolina General Statutes to the
Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, N.C. 27699-6714. This
certification and its conditions are final and binding unless you ask for a hearing.
This letter completes the review of the Division of Water Quality under Section 401 of the Clean
Water Act. If you have any questions, please telephone Ms. Cynthia Van Der Wiele at 919.733.5715
or Mr. Mike Parker of the Asheville Regional Office at 828.251.6208.
Sincerely,
ry . T orpe, D.
ctin Director
Attachment..
Pc: Wilmington District Corps of Engineers
Corps of Engineers 'Asheville`Fie-ld Office
NCDWQ Asheville Regional Office
Central Files f:
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STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY
GOVERNOR
P. O. BOX 77, WHITTIER, NC 28789
September 13, 2001
Mr. John R. Dorney
Division of Water Quality
401/ Wetlands Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
Subject: Nationwide 401 Permit Application
Bridge 136 on SR 1313 - Tributary to Canal Creek
Polk County
DWQ Project # 011171
Dear Mr. Dorney:
cop-? y
LYNDO TIPPETT
SECRETARY
In response to your letter posted September 4, 20011 have enclosed 7 copies of
our project's PCN application, a location map, and a plan and profile of the project in
Polk County. I have also included asi to map including the location of all streams and
ponds on the property and all corresponding stream impacts. The bridge will be replaced
with a 142" X 91" X 50' corrugated metal pipe arch.
Bridge #136 in Polk County is a small bridge that we are going to replace with a
142" 91 X 50' corrugated metal pipe arch. After closing and removing the old bridge
we will lower the streambed one foot below its original elevation. After placing the arch
we will then place stone rip-rap at the inlet and outlet of the pipe, as well as filling the
total fill volume from the top of the pipe to the original road elevation.
Bridge No. 136 spans a small stream that is a tributary to Canal Creek. The
drainage area for the stream is approximately 90% forest and woodlands. This site is not
in violation of any DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules.
Any potential impacts from sedimentation downstream of the project site will be avoided
by the implementation of appropriate BMP's.
Your earliest consideration for this request would be greatly appreciated.
If you have any questions or information needs, please call me at [phone].
Bridge No. 136 on SR 1313
Page 2 September 13, 2001
Your earliest consideration for this request would be greatly appreciated. If you
have any questions or information needs, please call me at [phone].
Sincerely,
fir- J.D. Metcalfe
Enclosures
BTW:btw
CC. Mr. Mark Davis, DEO
File
Division 14 Bridge Maintenance Engineer
Bridge Maintenance, P.O. B. 77, Whittier, NC 28789 Telephone [phone] Fax [phone]
micnaw r. tasiey, uovernor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Gregory J. Thorpe, Ph.D.
Acting Director
Division of Water Quality
August 21, 2001
DWQ # 011171
Polk County
Mr. J.D. Metcalfe, NCDOT
Bridge Maintenance Engineer
Division 14
Post Office Box 77
Whittier, NC 28789
Dear Mr. Metcalfe:
On August 2, 2001 the Division of Water Quality (DWQ) was notified by receipt of your applications regarding your plan to fill
streams for the purpose of replace Bridge No 136 on SR 1313 in Polk County. Approval from DWQ is required to disturb these
streams. Please provide seven copies of the following information and refer to the DWQ # listed above in your reply. In particular as
described in 15A NCAC 2B .0502, we will require you to locate all streams and ponds on the property on a site plan which also shows
all other related stream impacts. Also please let us know which Nationwide Permit the Corps of Enoineers has decided can be used for
this project. Please show these on maps of suitable scale (for instance 1" = 100 feet) so we can begin to determine your projects'
compliance with 15A NCAC 2H .0500.
Please call Cynthia Van Der Wiele at [phone] if you have any questions or would require copies of our rules or
procedural materials. This project will remain on hold as incomplete in accordance with 15A NCAC 2H .0505(c). The processing time
for this application will begin when this information is received. If we do not hear from you by writing within three (3) weeks we will
assume you no longer want to pursue the project and will consider it withdrawn.
Si c el ,
R. orney
Cc: Asheville DWQ Regional Office
Asheville Corps of Engineers
File Copy
Central Files
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BRIDGE MAINTENANCE UNIT
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Pre-Construction Notification (PCN) Application Form
For Section 404 and/or Section 10 Nationwide, Regional and General Permits, Section 401
General Water Quality Certifications, and Riparian Buffer and Watershed Buffer Rules
This form is to be used for projects qualifying for any of the U.S. Army Corps of Engineers' (USACE)
Nationwide, Regional or General Permits as required by Section 404 of the Clean Water Act and/or
Section 10 of the Rivers and Harbors Act, and for the North Carolina Division of Water Quality's
(DWQ) associated General 401 Water Quality Certifications. This form is also to be used for any
project requiring approval under any Riparian Buffer Rules implemented by the N.C. Division of Water
Quality. This form should not be used if you are requesting an Individual 404 Permit or Individual 401
Water Quality Certification. The USACE Individual Permit application form is available online at
http://www.saw.usace.army.mil/wetlands/Penn app.htm.
The USACE is the lead regulatory agency. To review the requirements for the use of Nationwide,
Regional or General permits, and to determine which permit applies to your project, please go to the
USACE website at hllp://www.saw.usace.ariny.mil/wetlands/rejztour.htm, or contact one of the field
offices listed at the end of this application. The website also lists the responsible project manager for
each county in North Carolina and provides additional information regarding the identification and
regulation of wetlands and waters of the U.S.
The DWQ issues a corresponding Certification (General or Individual), and cannot tell the applicant
which 401 Certification will apply until the 404 Permit type has been determined by the USACE.
Applicants are encouraged to visit DWQ's 401/Wetlands Unit website at
http://h2o.enr.state.nc.us/ncwetlands to read about current requirements for the 401 Water Quality
Certification Program and to determine whether or not Riparian Buffer Rules are applicable. The
applicant is also advised to read the full text of the General Certification (GC) matching the specific 404
Permit requested. In some cases, written approval for some General Certifications is not required,
provided that the applicant adheres to all conditions of the GC. Applicants lacking access to the internet
should contact DWQ's Central Office in Raleigh at [phone].
Trout Waters Coordination - Special coordination with the North Carolina Wildlife Resources
Commission (NCWRC) is also required for projects occurring in any of North Carolina's twenty-five
counties that contain trout waters. In such cases, the applicant should contact the appropriate NCWRC
regional coordinator (listed by county on the last page of this application).
Page 1 of 12
CAMA Coordination - If the project occurs in any of North Carolina's twenty coastal counties (listed on
the last page of this application) the applicant should also contact the North Carolina Division of Coastal
Management (DCM) at [phone]. DCM will determine whether or not the project involves a
designated Area of Environmental Concern, in which case DCM will act as the lead permitting agency.
In such cases, DCM will require a Coastal Area Management Act (CAMA) Permit and will coordinate
the 404/401 Permits.
USACE Permits - Submit one copy of this form, along with supporting narratives, maps, data forms,
photos, etc. to the applicable USACE Regulatory Field Office (addresses are listed at the end of this
application). Upon receipt of an application, the USACE will determine if the application is complete as
soon as possible, not to exceed 30 days. This PCN form is designed for the convenience of the applicant
to address information needs for all USACE Nationwide, Regional or General permits, as well as
information required for State authorizations, certifications, and coordination. Fully providing the
information requested on this form will result in a complete application for any of the USACE
Nationwide, Regional or General permits. To review the minimum amount of information that must be
provided for a complete PCN for each USACE Nationwide permit, see Condition 13, 65 Fed.Reg. 12893
(March 9, 2000), available at http://www.saw.usace.army.mil/wetlands/nwpfinalFedRegpdf.
Processing times vary by permit and begin once the application has been determined to be complete.
Please contact the appropriate regulatory field office for specific answers to permit processing periods.
401 Water Quality Certification or Buffer Rules - All information is required unless otherwise stated
as optional. Incomplete applications will be returned. Submit seven collated copies of all USACE
Permit materials to the Division of Water Quality, 401/Wetlands Unit, 1650 Mail Service Center,
Raleigh, NC, 27699-1650. If written approval is required or specifically requested for a 401
Certification, then a non-refundable application fee is required. In brief, if project impacts include less
than one acre of cumulative wetland/water impacts and less than 150 feet cumulative impacts to
streams, then a fee of $200 is required. If either of these thresholds is exceeded, then a fee of $475 is
required. A check made out to the North Carolina Division of Water Quality, with the specific name of
the project or applicant identified, should be stapled to the front of the application package. For more
information, see the DWQ website at http://h2o.ehnr.state.nc.us/ncwetlands/fees.html. The fee must be
attached with the application unless the applicant is a federal agency in which case the check may be
issued from a separate office. In such cases, the project must be identifiable on the U.S. Treasury check
so that it can be credited to the appropriate project. If written approval is sought solely for Buffer Rules,
the application fee does not apply, and the applicant should clearly state (in a cover letter) that only
Buffer Rule approval is sought in writing. Wetlands or waters of the U.S. may not be impacted prior to
issuance or waiver of a Section 401 Water Quality Certification. Upon receipt of a complete application
for a 401 Certification, the Division of Water Quality has 60 days to prepare a written response to the
applicant. This may include a 401 Certification, an on-hold letter pending receipt of additional
requested information, or denial.
Page 2 of 12
Office Use Only: Form Version April 2001
USACE Action ID No. DWQ No.
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
1. Processing
1. Check all of the approval(s) requested for this project:
® Section 404 Permit
? Section 10 Permit
® 401 Water Quality Certification
? Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested:
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: ?
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here: ?
II. Applicant Information
1. Owner/Applicant Information
Name: NC Department of Transportation c/o J.D. Metcalfe
Mailing Address: PO Box 77 Whittier, NC 28789
Telephone Number: 1-828-497-7953 Fax Number: 1-828-497-6095
E-mail Address: jmetcalfekdot.state.nc.us
2. Agent Information (A signed and dated copy of the Agent Authorization letter must be
attached if the Agent has signatory authority for the owner/applicant.)
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
Page 3 of 12
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, ` DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project: Bridge 136 over Creek on SR 1313 in Polk County.
2. T.I.P. Project Number (NCDOT Only):
3. Property Identification Number (Tax PIN):
4. Location
County: Polk Nearest Town: Mill Springs
Subdivision name (include phase/lot number):
Directions to site (include road numbers, landmarks, etc.): From Raleigh proceed on I-40
West to Asheville and take I-26 West in Asheville. Proceed on I-26 past Hendersonville and
exit on US 74 (Columbus). Go east about two miles and exit onto highway 108 East. Travel
3.3 miles east on highway 108 and take a left on highway 9. Travel .5 miles north on
highway 9 and take a right on SR 1313. The bridge will be 1.2 miles ahead.
5. Site coordinates, if available (UTM or Lat/Long): 35D 19' 4" 82D 9' 45"
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Describe the existing land use or condition of the site at the time of this application:
Farmland
7. Property size (acres):
8. Nearest body of water (stream/river/sound/ocean/lake): Canal Creek
9. River Basin: Broad
Page 4 of 12
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at htlp://h2o.enr.state.nc.us/admin/maps/.)
Describe the purpose of the proposed work: Bridge #136 in Polk County is a small bridge
that we are going to replace with a 142" x 91" x 50' corrugated metal pipe arch. After
closing and removing the old bridge we will lower the streambed 1 foot below its original
elevation. After placing the culvert we will then place stone rip-rap at the inlet and outlet of
the pipe, as well as filling in the total fill volume from the top of the pipe to the original road
elevation. The headwall will then be poured.
10. List the type of equipment to be used to construct the project:
Backhoe boomtruck etc.
11. Describe the land use in the vicinity of this project: farmland
IV. Prior Project History
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.
DWQ Project # 011171
V. Future Project Plans
Are any additional permit requests anticipated for this project in the future? If so, describe the
anticipated work, and provide justification for the exclusion of this work from the current
application: No future permits or work is anticipated for this project.
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
Page 5 of 12
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the impact in Section VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
1. Wetland Impacts
Wetland Impact
Site Number
(indicate on ma)
Type of Impact* Area of
Impact
(acres) Located within
100-year Floodplain**
(es/no) Distance to
Nearest Stream
(linear feet)
Type of Wetland***

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized clearing, grading, fill,
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at http://www.fema.gov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.)
List the total acreage (estimated) of existing wetlands on the property: 0
Total area of wetland impact proposed: 0
2. Stream Impacts, including all intermittent and perennial streams
Stream Impact
Site Number
indicate on ma)
Type of Impact* Length of
Impact
(linear feet)
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
leasespecify)
1 CMPA & rip-rap 50 Trib. To Canal Creek 5' Perennial

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
Page 6 of 12
** Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online' at
www.usgs.gov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.topozone.com,
www.mgpguest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: 50'
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U.S.
Open Water Impact
Site Number
(indicate on ma)
Type of Impact* Area of
Impact
(acres) Name of Waterbod
y
(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. Pond Creation
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): ? uplands ? stream ? wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
Silt fence will be used around the nroiect to reduce run-off into the stream. Also check dams
will be placed downstream of the project to collect silt that may enter the stream.
Page 7 of 12
VIII, Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
hqp://h2o.enr.state.nc.us/ncwetlands/stnnizide.html.
1. Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
Page 8 of 12
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at http://h2o.enr.state.nc.us/wo/index.htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes ® No ?
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ? No
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes ? No
X. Proposed Impacts on Riparian and Watershed Buffers (DWQ Only)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Page 9 of 12
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes ? No ® If you answered "yes", provide the following information:
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* Impact
(square feet) Multiplier Required
Mitigation
1 3
2 1.5
Total
* Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or .0260.
XI. Stormwater (DWQ Only)
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
The drainage area for the small creek is approximately 90-95% forest and woodlands. Silt fence
will be used around the project to reduce run-off into the stream.
XII. Sewage Disposal (DWQ Only)
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.
No wastewater will be generated from the project.
Page 10 of 12
XIII. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit application?
Yes ? No
XIV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
--r, ?,i
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
US Army Corps Of Engineers Field Offices and County Coverage
D
Asheville Regulatory Field Office Alexander Cherokee Iredell Mitchell Union
US Army Corps of Engineers Avery Clay Jackson Polk Watauga
151 Patton Avenue Buncombe Cleveland Lincoln Rowan Yancey
Room 208 Burke Gaston Macon Rutherford
Asheville, NC 28801-5006 Cabarrus Graham Madison Stanley
Telephone: [phone] Caldwell Haywood McDowell Swain
Fax: [phone] Catawba Henderson Mecklenburg Transylvania
Raleigh Regulatory Field Office Alamance Durham Johnston Rockingham Wilson
US Army Corps Of Engineers Alleghany Edgecombe Lee Stokes Yadkin
6508 Falls of the Neuse Road Ashe Franklin Nash Surry
Suite 120 Caswell Forsyth Northampton Vance
Raleigh, NC 27615 Chatham Granville Orange Wake
Telephone: [phone] Davidson Guilford Person Warren
Fax: [phone] Davie Halifax Randolph Wilkes
Washington Regulatory Field Office Beaufort Currituck Jones Pitt
US Army Corps Of Engineers Bertie Dare Lenoir Tyrrell
Post Office Box 1000 Camden Gates Martin Washington
Washington, NC 27889-1000 Carteret* Green Pamlico Wayne
Page 11 of 12
Telephone: [phone] Chowan Hertford Pasquotank
Fax: [phone] Craven Hyde Perquimans *Croatan National Forest Only
Wilmington Regulatory Field Office Anson Duplin Onslow
US Army Corps Of Engineers Bladen Harnett Pender
Post Office Box 1890 Brunswick Hoke Richmond
Wilmington, NC 28402-1890 Carteret Montgomery Robeson
Telephone: [phone] Columbus Moore Sampson
Fax: [phone] Cumberland New Hanover Scotland
US Fis
US Fish and Wildlife Service
Raleigh Field Office
Post Office Box 33726
Raleigh, NC 27636-3726
Telephone: [phone]
h and Wildlife Service / National N
US Fish and Wildlife Service
Asheville Field Office
160 Zillicoa Street
Asheville, NC 28801
Telephone: [phone]
[arine Fisheries Service
National Marine Fisheries Service
Habitat Conservation Division
Pivers Island
Beaufort, NC 28516
Telephone: [phone]
North Carolina State Agencies
Division of Water Quality
401 Wetlands Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
Telephone: [phone]
Fax: [phone]
Division of Water Quality
Wetlands Restoration Program
1619 Mail Service Center
Raleigh, NC 27699-1619
Telephone: [phone]
Fax: [phone]
CAMA and NC Coastal Counties
State Historic Preservation Office
Department Of Cultural Resources
4617 Mail Service Center
Raleigh, NC 27699-4617
Telephone: [phone]
Fax: [phone]
Division of Coastal Management Beaufort Chowan Hertford Pasquotank
1638 Mail Service Center Bertie Craven Hyde Pender
Raleigh, NC 27699-1638 Brunswick Currituck New Hanover Perquimans
Telephone: [phone] Camden Dare Onslow Tyrrell
Fax: [phone] Carteret Gates Pamlico Washington
NCWRC and NC Trout Counties
Western Piedmont Region Coordinator Alleghany Caldwell Watauga
3855 Idlewild Road Ashe Mitchell Wilkes
Kernersville, NC 27284-9180 Avery Stokes
Telephone: [phone] Burke Surry
Mountain Region Coordinator Buncombe Henderson Polk
20830 Great Smoky Mtn. Expressway Cherokee Jackson Rutherford
Waynesville, NC 28786 Clay Macon Swain
Telephone: [phone] Graham Madison Transylvania
Fax: [phone] Haywood McDowell Yancey
Page 12 of 12
r
John R. Dorney
D
N? T
Dear Mr 9 ?1 v5

On ?a 2 the Divis, of Water Quality (D ) was notified by receip of your
egar ing your plan to fill rd's for the purpose of in
applications regarding'
County. Approval from DWQ is required to disturb these . Please provide seven copies
of the following information and refer to the DWQ # listed above in your reply. In particular as described in
15A NCAC 2B .0502, we will require you to locate all streams and ponds on the property Please show
these on maps of suitable scale (for instance V = 100 feet) so we can begin to determin your projects'
compliance with 15A NCAC 2H.0500.
Please call we at [phone] if you have any questions or would require
procedural material . This project will remain on hold as incomplete in accordance
.0505(c). The pro sslf g time for this application will begin when this information is r
hear from you by riling within three (3) weeks we will assume you no longer want t
Will consider it thdrawn.
Michael F. Easley
Governor
William G. Ross,Jr.Secretary
Department of Environment and Natural Resources
131Zb-0)
011!7 1
A County
?V
`? 3 l3
( I
Sincerely, 0, 1

Cc: DWQ Regional Office
%1%\ rps of Engineers
A -"J
opy
File
Central Files
3?
AG
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51+2
lei C15.
?, usep
Kerr T. Stevens
Division of Water Quality
i of our rules or
15A NCAC 2H
A. If we do not
the project and
Cr1l, (Y?_y

C1./l? C loc? ,u-5 - vva?+ A

Division of Water Quality 1650 Mail Service Center Raleigh, NC 27699-1650
Wetlands1401 Unit [phone]
Fax: [phone]
01 1171
? kx?t
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY P. O. BOX 77, WHITTIER, NC 28789
GOVERNOR
July 18, 2001
Mr. Robert Ridings
Division of Water Quality
401/ Wetlands Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
Subject: Nationwide 401 Permit Application
Bridge 136 on SR 1313 - Tributary to Canal Creek
Polk County
Dear Mr. Ridings:
LYNDO TIPPETT
SECRETARY

I have enclosed a PCN application, a location map, and a brief project description
for the replacement of Bridge No. 136 on SR 1313 in Jackson County. The bridge will
be replaced with a 142" X 91" X 50' corrugated metal pipe arch.
Bridge #136 in Polk County is a small bridge that we are going to replace with a
142" x 91" x 50' corrugated metal pipe arch. After closing and removing the old bridge
we will lower the streambed 1 foot below its original elevation. After placing the culvert
we will then place stone rip-rap at the inlet and outlet of the pipe, as well as filling in the
total fill volume from the top of the pipe to the original road elevation. The headwall will
then be poured.
Bridge No. 136 spans a small stream that is a tributary to the Canal Creek. The
drainage area for the stream is approximately 90 - 95% forest and woodlands. This site is
not in violation of any DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules.
Any potential impacts from sedimentation downstream of the project site will be avoided
by the implementation of appropriate BMP's.
Your earliest consideration for this request would be greatly appreciated.
If you have nay questions or information needs, please call me at [phone].
tT iy
OFD
Bridge No. 136 on SR 1313 Page 2 July 18, 2001
Your earliest consideration for this request would be greatly appreciated. If you
have any questions or information needs, please call me at [phone].
Sincerely, Q
Cpl ?
J.D. Metcalfe
Division 14 Bridge Maintenance Engineer
Enclosures
BTW:btw
CC. Mr. Mark Davis, DEO
File
Bridge Maintenance, P.O. B. 77, Whittier, NC 28789 Telephone [phone] Fax [phone]
P ?
C?
of
Pre-Construction Notification (PCN) Application Form
For Section 404 and/or Section 10 Nationwide, Regional and General Permits, Section 401
General Water Quality Certifications, and Riparian Buffer and Watershed Buffer Rules
This form is to be used for projects qualifying for any of the U.S. Army Corps of Engineers' (USACE)
Nationwide, Regional or General Permits as required by Section 404 of the Clean Water Act and/or
Section 10 of the Rivers and Harbors Act, and for the North Carolina Division of Water Quality's
(DWQ) associated General 401 Water Quality Certifications. This form is also to be used for any
project requiring approval under any Riparian Buffer Rules implemented by the N.C. Division of Water
Quality. This form should not be used if you are requesting an Individual 404 Permit or Individual 401
Water Quality Certification. The USACE Individual Permit application form is available online at
http://www.saw.usace.army.mil/wetlands/Perm app htm.
The USACE is the lead regulatory agency. To review the requirements for the use of Nationwide,
Regional or General permits, and to determine which permit applies to your project, please go to the
USACE website at hqp://www.saw.usace.anny.mil/wetlands/regtour.htrn, or contact one of the field
offices listed at the end of this application. The website also lists the responsible project manager for
each county in North Carolina and provides additional information regarding the identification and
regulation of wetlands and waters of the U.S.
The DWQ issues a corresponding Certification (General or Individual), and cannot tell the applicant
which 401 Certification will apply until the 404 Permit type has been determined by the USACE.
Applicants are encouraged to visit DWQ's 401/Wetlands Unit website at
http://h2o.enr.state.nc.us/ncwetlands to read about current requirements for the 401 Water Quality
Certification Program and to determine whether or not Riparian Buffer Rules are applicable. The
applicant is also advised to read the full text of the General Certification (GC) matching the specific 404
Permit requested. In some cases, written approval for some General Certifications is not required,
provided that the applicant adheres to all conditions of the GC. Applicants lacking access to the internet
should contact DWQ's Central Office in Raleigh at [phone].
Trout Waters Coordination - Special coordination with the North Carolina Wildlife Resources
Commission (NCWRC) is also required for projects occurring in any of North Carolina's twenty-five
counties that contain trout waters. In such cases, the applicant should contact the appropriate NCWRC
regional coordinator (listed by county on the last page of this application).
Page 1 of 12
CAMA Coordination - If the project occurs in any of North Carolina's twenty coastal counties (listed on
the last page of this application) the applicant should also contact the North Carolina Division of Coastal
Management (DCM) at [phone]. DCM will determine whether or not the project involves a
designated Area of Environmental Concern, in which case DCM will act as the lead permitting agency.
In such cases, DCM will require a Coastal Area Management Act (LAMA) Permit and will coordinate
the 404/401 Permits.
USACE Permits - Submit one copy of this form, along with supporting narratives, maps, data forms,
photos, etc. to the applicable USACE Regulatory Field Office (addresses are listed at the end of this
application). Upon receipt of an application, the USACE will determine if the application is complete as
soon as possible, not to exceed 30 days. This PCN form is designed for the convenience of the applicant
to address information needs for all USACE Nationwide, Regional or General permits, as well as
information required for State authorizations, certifications, and coordination. Fully providing the
information requested on this form will result in a complete application for any of the USACE
Nationwide, Regional or General permits. To review the minimum amount of information that must be
provided for a complete PCN for each USACE Nationwide permit, see Condition 13, 65 Fed.Reg. 12893
(March 9, 2000), available at hgp://www.saw.usace.anny.mil/wetlands/nwpfinalFedReg_pdf.
Processing times vary by permit and begin once the application has been determined to be complete.
Please contact the appropriate regulatory field office for specific answers to permit processing periods.
401 Water Quality Certification or Buffer Rules - All information is required unless otherwise stated
as optional. Incomplete applications will be returned. Submit seven collated copies of all USACE
Permit materials to the Division of Water Quality, 401/Wetlands Unit, 1650 Mail Service Center,
Raleigh, NC, 27699-1650. If written approval is required or specifically requested for a 401
Certification, then a non-refundable application fee is required. In brief, if project impacts include less
than one acre of cumulative wetland/water impacts and less than 150 feet cumulative impacts to
streams, then a fee of $200 is required. If either of these thresholds is exceeded, then a fee of $475 is
required. A check made out to the North Carolina Division of Water Quality, with the specific name of
the project or applicant identified, should be stapled to the front of the application package. For more
information, see the DWQ website at http://h2o.chnr.state.nc.us/ncwetlands/fees.html. The fee must be
attached with the application unless the applicant is a federal agency in which case the check may be
issued from a separate office. In such cases, the project must be identifiable on the U.S. Treasury check
so that it can be credited to the appropriate project. If written approval is sought solely for Buffer Rules,
the application fee does not apply, and the applicant should clearly state (in a cover letter) that only
Buffer Rule approval is sought in writing. Wetlands or waters of the U.S. may not be impacted prior to
issuance or waiver of a Section 401 Water Quality Certification. Upon receipt of a complete application
for a 401 Certification, the Division of Water Quality has 60 days to prepare a written response to the
applicant. This may include a 401 Certification, an on-hold letter pending receipt of additional
requested information, or denial.
Page 2 of 12
Office Use Only: Form Version April 2001
USACE Action ID No. DWQ No. 011171.
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
1. Processing
1. Check all of the approval(s) requested for this project:
® Section 404 Permit
? Section 10 Permit
® 401 Water Quality Certification
? Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested:
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: ?
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here: ?
II. Applicant Information
1. Owner/Applicant Information
Name: NC Department of Transportation c/o J.D. Metcalfe
Mailing Address: PO Box 77 Whittier, NC 28789
Telephone Number: 1-828-497-7953 Fax Number: 1-828-497-6095
E-mail Address: jmetcalfegdot.state.nc.us
2. Agent Information (A signed and dated copy of the Agent Authorization letter must be
attached if the Agent has signatory authority for the owner/applicant.)
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
Page 3 of 12
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project: Bridge 136 over Creek on SR 1313 in Polk County.
2. T.I.P. Project Number (NCDOT Only):
3. Property Identification Number (Tax PIN):
4. Location
County: Polk Nearest Town: Mill Springs
Subdivision name (include phase/lot number):
Directions to site (include road numbers, landmarks, etc.):
5. Site coordinates, if available (UTM or Lat/Long):
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Describe the existing land use or condition of the site at the time of this application:
Farmland
7. Property size (acres):
8. Nearest body of water (stream/river/sound/ocean/lake): Canal Creek
9. River Basin: Broad
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/maps/.)
Page 4 of 12
Describe the purpose of the proposed work: Bridge #136 in Polk County is a small bridge
that we are going to replace with a 142" x 91" x 50' corrugated metal pipe arch. After
closing and removing the old bridge we will lower the streambed 1 foot below its original
elevation. After placing the culvert we will then place stone rip-rap at the inlet and outlet of
the pipe, as well as filling in the total fill volume from the top of the pipe to the original road
elevation. The headwall will then be poured.
10. List the type of equipment to be used to construct the project:
Backhoe, boomtruck, etc.
11. Describe the land use in the vicinity of this project: farmland
IV. Prior Project History
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.
V. Future Project Plans
Are any additional permit requests anticipated for this project in the future? If so, describe the
anticipated work, and provide justification for the exclusion of this work from the current
application:
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
Page 5 of 12
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the impact in Section VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
1. Wetland Impacts
Wetland Impact
Site Number
(indicate on map)
Type of Impact* Area of
Impact
(acres) Located within
100-year Floodplain**
(es/no) Distance to
Nearest Stream
(linear feet)
Type of Wetland***

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized clearing, grading, fill,
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at http://www.fema.aov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.)
List the total acreage (estimated) of existing wetlands on the property: 0
Total area of wetland impact proposed: 0
2. Stream Impacts, including all intermittent and perennial streams
Stream Impact
Site Number
(indicate on ma)
Type of Impact* Length of
Impact
(linear feet)
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
leases eci )
1 CMPA & rip-rap 50 Trib. To Canal Creek 5' Perennial

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
www.usgs.gov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.topozone.com,
www.mWquest.com, etc.).
Page 6 of 12
Cumulative impacts (linear distance in feet) to all streams on site: 50'
3. Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U.S.
Open Water Impact
Site Number
(indicate on ma)
Type of Impact* Area of
Impact
(acres) Name of Waterbody
(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.)

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. Pond Creation
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): ? uplands ? stream ? wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
Silt fence will be used around the project to reduce run-off into the stream.
Page 7of12
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
http://h2o.enr.state.nc.us/ncwetlands/strmgide.html.
1. Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), effected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
Page 8 of 12
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at hqp://h2o.enr.state.nc.us/Ma/index.htrn. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes Z No ?
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ? No
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes ? No
X. Proposed Impacts on Riparian and Watershed Buffers (DWQ Only)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Page 9 of 12
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes ? No ® If you answered "yes", provide the following information:
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* Impact
(square feet) Multiplier Required
Mitigation
1 3
2 1.5
Total
* Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or .0260.
Xl. Stormwater (DWQ Only)
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
The drainage area for the small creek is approximately 90-95% forest and woodlands. Silt fence
will be used around the project to reduce run-off into the stream.
XII. Sewage Disposal (DWQ Only)
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.
No wastewater will be generated from the project.
XIII. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Page 10 of 12
Yes ? No
Is this an after-the-fact permit application?
Yes ? No
XIV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
-Z5
Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
US Army Corps Of Engineers Field Offices and County Coverage
Asheville Regulatory Field Office Alexander Cherokee Iredell Mitchell
US Army Corps of Engineers Avery Clay - Jackson Polk
151 Patton Avenue Buncombe Cleveland Lincoln Rowan
Room 208 Burke Gaston Macon Rutherford
Asheville, NC 28801-5006 Cabarrus Graham Madison Stanley
Telephone: [phone] Caldwell Haywood McDowell Swain
Fax: [phone] Catawba Henderson Mecklenburg Transylvania
Raleigh Regulatory Field Office Alamance Durham Johnston Rockingham
US Army Corps Of Engineers Alleghany Edgecombe Lee Stokes
6508 Falls of the Neuse Road Ashe Franklin Nash Surry
Suite 120 Caswell Forsyth Northampton Vance
Raleigh, NC 27615 Chatham Granville Orange Wake
Telephone: [phone] Davidson Guilford Person Warren
Fax: [phone] Davie Halifax Randolph Wilkes
Washington Regulatory Field Office Beaufort Currituck Jones
US Army Corps Of Engineers Bertie Dare Lenoir
Post Office Box 1000 Camden Gates Martin
Washington, NC 27889-1000 Carteret* Green Pamlico
Telephone: [phone] Chowan Hertford Pasquotank
Fax: [phone] Craven Hyde Perquimans
Pitt
Tyrrell
Washington
Wayne
Union
Watauga
Yancey
Wilson
Yadkin
*Croatan National Forest Only
Page 11 of 12
Wilmington Regulatory Field Office Anson Duplin Onslow
US Army Corps Of Engineers Bladen Harnett Pender
Post Office Box 1890 Brunswick Hoke Richmond
Wilmington, NC 28402-1890 Carteret Montgomery Robeson
Telephone: [phone] Columbus Moore Sampson
Fax: [phone] Cumberland New Hanover Scotland
US Fish and Wildlife Service / National Marine Fisheries Service
US Fish and Wildlife Service US Fish and Wildlife Service National Marine Fisheries Service
Raleigh Field Office Asheville Field Office Habitat Conservation Division
Post Office Box 33726 160 Zillicoa Street Pivers Island
Raleigh, NC 27636-3726 Asheville, NC 28801 Beaufort, NC 28516
Telephone: [phone] Telephone: [phone] Telephone: [phone]
North Carolina State Agencies
Division of Water Quality
401 Wetlands Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
Telephone: [phone]
Fax: [phone]
Division of Water Quality
Wetlands Restoration Program
1619 Mail Service Center
Raleigh, NC 27699-1619
Telephone: [phone]
Fax: [phone]
State Historic Preservation Office
Department Of Cultural Resources
4617 Mail Service Center
Raleigh, NC 27699-4617
Telephone: [phone]
Fax: [phone]
CAMA and NC Coastal Counties
Division of Coastal Management Beaufort Chowan Hertford Pasquotank
1638 Mail Service Center Bertie Craven Hyde Pender
Raleigh, NC 27699-1638 Brunswick Currituck New Hanover Perquimans
Telephone: [phone] Camden Dare Onslow Tyrrell
Fax: [phone] Carteret Gates Pamlico Washington
NCWRC and NC Trout Counties
Western Piedmont Region Coordinator Alleghany Caldwell Watauga
3855 Idlewild Road Ashe Mitchell Wilkes
Kernersville, NC 27284-9180 Avery Stokes
Telephone: [phone] Burke Surry
Mountain Region Coordinator Buncombe Henderson Polk
20830 Great Smoky Mtn. Expressway Cherokee Jackson Rutherford
Waynesville, NC 28786 Clay Macon Swain
Telephone: [phone] Graham Madison Transylvania
Fax: [phone] Haywood McDowell Yancey
Page 12 of 12
IF INCORRECT RETURN TO
NC DEPARTMENT OF TRANSPORTATION
'DIVISION"-I4"OFFICE
8285862141
WARRANT NO. 11506
INVOICE NUMBER INVOICE DATE INVOICE AMOUNT
0726092310 7/25/2001 $200.00
I
DATE 07/26/2001
NET AMOUNT
$200.00