20100455 Ver 1_Application_20100609

V 7TP.9 Office Use Only:
o 1 10 0 4 5 5 Corps action ID no.
o DWQ project no.
Form Version 1.3 Dec 10 2008
Pre-Construction Notification (PCN) Form
A. Applicant Information
1. Processing -
1 a. Type(s) of approval sought from the

Corps: non-reporting
®Section 404 Permit El Section 10 Permit
lb. Specify Nationwide Permit (NWP) number: NWP 3 or General Permit (GP) number:
1c. Has the NWP or GP number been verified by the Corps? ? Yes M 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 M Riparian Buffer Authorization
le. Is this notification solely for the record
because written approval is not required? For the record only for DWQ 401
Certification:
M Yes ? No For the record only for Corps.Permit:

M 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 or in-lieu
fee program. ? Yes N No
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1h
below. ? Yes ®-,No!, ,.
1 h. Is the project located within a INC DCM Area of Environmental Concern (AEC)? ? Yes M-No,
.
2.
2 Project Information ;
2a. Name of project: Proposed extension of a cross line conveying an unnamed tributary to, Deep Creek on
US 158 in between Ivy Day Road and Evelyn Day Road.
2b. County: Person
2c. Nearest municipality / town: Roxboro
2d. Subdivision name: N/A .. ,..... .
2e. NCDOT only, T.I.P. or state
project no:
3. Owner Information D '?
3a. Name(s) on Recorded Deed: NCDOT Division 5
3b. Deed Book and Page No. N/A JUN 0 q
3c. Responsible Party (for LLC if
applicable): N/A
DDIR-WATERQU W
3d. Street address: 2612 N. Duke Street
3e. City, state, zip: Durham, NC 27704
3f. Telephone no.: [phone]
3g. Fax no.: [phone]
3h. Email address: wbowman(a)ncdot.gov
4. Applicant Information (if different from owner) N/A
5. Agent/Consultant Information (if applicable) N/A
Page 1 of 8
PCN Form - Version 1.3 December 10, 2008 Version
B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID): N/A
1 b. Coordinates (in decimal degrees):
Site: Latitude:36.3579 Longitude: -78.9267
(DD.DDDDDD) (-DD.DDDDDD)
1 c. Property size: < 0.01 acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to Deep Creek
proposed project:
2b. Water Quality Classification of nearest receiving water: WS-III NSW
2c. River basin: Neuse
3. Project Description
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:
There is currently no shoulder section above the outlet of this structure, which is a safety concern. Site is surrounded by
woode&agricultural lands. rj .:
3b. List the total estimated acreage of all existing wetlands on the property: ;a: r •,. ,
NONE ; .._
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:: ..,. -
60 ft
3d. Explain the purpose of the proposed project: The pipe extension will allow for an adequate and safer, shoulder section
through this'crossing.
3e. Describe the overall project in detail, including the type of equipment to be used: „
8 feet of 48 inch will be added to the outlet end of this structure. A concrete collar will be poured to help secure the pipe
extension to the old headwall. The area will then be back filled to provide an adequate shoulder section. Rip rap will be
installed underlined with filter fabric for long term stability surrounding the mouth of the pipe extension.as well as along
the stream banks where the lower ends of the ditches tie to the stream very near the pipe outlet. Equipment may, include
a backhoe, an excavator, and grader.
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 prior phases) in the past?
Comments: N/A
41b. If the Corps made the jurisdictional determination, what type
? Preliminary ? Final
of determination was made?
4c. If yes, who delineated the jurisdictional areas? Agency/Consultant Company: N/A
Name (if known): N/A Other: N/A
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
N/A
5. Project History
5a. Have permits or certifications been requested or obtained for ? Yes ® No ? Unknown
this project (including all prior phases) in the past?
5b. If yes, explain in detail according to "help file" instructions.
N/A

Page 2 of 8
PCN Form - Version 1.3 December 10, 2008 Version
6. Future Project Plans
6a. Is this a phased project? ? Yes ®No
6b. If yes, explain.
N/A
C. Proposed Impacts Inventory
1. Impacts Summary
1a. Which sections were completed below for your project (check all that apply):
? Wetlands ® Streams - tributaries ® Buffers
? Open Waters ? Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a. 2b. 2c. 2d. 2e. 2f.
Wetland impact Type of jurisdiction
number - Type of impact Type of wetland Forested (Corps - 404, 10 Area of impact
Permanent (P) or (if known) DWQ - non-404, other) (acres)
Temporary T
W 1 ? P ? T N/A N/A ? Yes ? Corps N/A
? No ? DWQ
2g. Total Wetland Impacts: NONE
2h. Comments: N/A
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then corplete this
question for all stream sites impacted.,., Sif .'.._..
3a. 3b. 3c. 3d. 3e. 3f. 3g:
Stream impact Type of impact Stream name Perennial Type of jurisdiction Average Impact
number - (PER) or (Corps - 404, 10 stream length
Permanent (P) or intermittent DWQ - non404,'• ^ width,:, (linear
Temporary, (T), (INT)? other) ^' feet) feet)
Site 1 ® P 0 T,•.
fill
UT to Deep Creek ® PER ® Corps ,
8
Stream 1 ? INT ® DWQ
Site 1 ® P ? T ® PER ® Corps

Stream 1 rip rap UT I o Deep Creek
?INT
® DWQ 3 30
3h. Total stream and tributary impacts.. 38
3i. Comments: rip rap will be placed on banks only for stabilization, not within the flow line
4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individually list all open water impacts below. -
4a. 4b. 4c. 4d. 4e.
Open water impact Name of waterbody
number- (if applicable) Type of impact Waterbody type Area of impact (acres)
Permanent (P) or
Temporary T
Ot ? P ? T N/A N/A N/A N/A
4f. Total open water impacts NONE
4g. Comments: N/A

Page 3 of 8
PCN Form - Version 1.3 December 10, 2008 Version
5. Pond or Lake Construction.
If and or lake construction proposed, then complete the chart below.
5a. 5b. 5c. 5d. 5e.
Wetland Impacts (acres) Stream Impacts (feet) Upland
Pond ID proposed use or purpose of (acres)
number pond
Flooded Filled Excavated Flooded Filled Excavated Flooded
P1 N/A N/A N/A N/A N/A N/A N/A N/A
P2
5f. Total NONE NONE NONE NONE NONE NONE NONE
5g. Comments: N/A
5h. Is a dam high hazard permit required?
? Yes N No If yes, permit ID no: N/A
5i. Expected pond surface area (acres): N/A
5j. Size of pond watershed (acres): N/A
5k. Method of construction: N/A
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If an impacts require mitigation, then you MUST fill out Section D of this form.

.6 a.
. N Neuse ? Tar-Pamlico' ? Other:.
Project is in which protected basin? ? Catawba ? Randleman
6b. 6c. ` 6d. 6e. 6f. 6g:
Buffer impact
number- • . Reason for Buffer Zone 1 impact Zone 2 impact
Permanent (P) or impact Stream name mitigation ;?- i (square feet)- (square'feet)
Temporary T required?.
Site N P ? T. ? Yes

Buffer Impact 1 Rip rap UT to Deep Creek
N No 2 ,700 SF 1,200 SF

6h. Total buffer impacts NONE 3,900 SF
6i. Comments: not to exceed 40 linear feet of new disturbance beyond existing transportation facility, 201ft on either side
D. Impact Justification and Mitigation ..
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
The impacts to riparian buffers will be limited to those necessary to access the stream, dewater, and to extend this pipe. Most
of the access will utilize the space within the existing transportation facility down the fill slope. This extension cannot be
performed without access through the riparian buffer.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Sediment and erosion control Best Management Practices for protection of surface waters and riparian buffers will be
enforced during project construction.
Page 4 of 8
PCN Form - Version 1.3 December 10, 2008 Version

2. Compensatory Mitigation for Impacts 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? ? Yes ® No
2b. If yes, mitigation is required by (check all that apply): ? DWQ ? Corps

2c. If yes, which mitigation option will be used for this project? ? Mitigation bank
? Payment to in-lieu fee program
? Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank: N/A
3b. Credits Purchased (attach receipt and letter) Type N/A Quantity N/A
3c. Comments: N/A
4. Complete if Making a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached. ? Yes
4b. Stream mitigation requested: N/A linear feet
'4c. If using stream mitigation, stream temperature: L1 warm '-? cool ?cold
4d. Buffer mitigation requested (DWQ only): N/A square feet
4e. Riparian wetland mitigation requested: N/A acres 6>' ,
4f:-Non-riparian wetland mitigation requested: N/A acres

4 Coastal (tidal) wetl6n6miti9ation requested:
9
N/A acres
41h. Comments. N/A '.;.
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. . , . .
N/A
6. Buffer Mitigation (State Regulated Riparian Buffer Rules), required by DWQ
6a. Will the project result in an impact within a. protected. riparian buffer that requires
buffer mitigation? .. ., ? Yes ®No ...
61b. 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.

Zone 6c.
Reason for impact 6d.
Total impact
(square feet)
Multiplier 6e.
Required mitigation
(square feet)
Zone 1 N/A N/A 3 (2 for Catawba) N/A
Zone 2 N/A N/A 1.5 N/A
6f. Total buffer mitigation required: NONE
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). N/A
6h. Comments: N/A

x
Page 5 of 8
PCN Form - Version 1.3 December 10, 2008 Version
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
la. Does the project include or is it adjacent to protected riparian buffers identified ® Yes ? No
within one of the NC Riparian Buffer Protection Rules?
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
? Yes No
Comments: this pipe extension will not alter storm water runoff at this site
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project? 20%
2b. Does this project require a Stormwater Management Plan? ? Yes ®No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why: NCD OT state Permit No. NCS000250
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, na rrative description of the plan: N/A
? Certified Local Government
2e. Who will be responsible for the review of the Stormwater Management Plan? ? DWQ Stormwater Program
? DWQ 401 Unit
3. Certified-Local ' Government Stormwater Review
3a. In which local government's jurisdiction-is this project? Franklin County,
? Phase II
El NSW
3b . Which of the following locally-implemented stormwater management programs . . ? USMP
apply (check alf that apply): ? Water Supply Water'shed'
? Other:
3c. Has the approved Stormwater Management Plan with proof of approval been ? Yes ? No....
attached? N/A
4. DWQ Stormwater Program Review
? Coastal counties
? HOW
4a . Which of the following state-implemented stormwater management programs apply ? ORW
(check all that apply): N/A ? Session Law 2006-246
? Other:
4b. Has the approved Stormwater Management Plan with proof of approval been
? Yes ? No
attached? N/A
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements? N/A ? Yes ? No
51b. Have all of the 401 Unit submittal requirements been met? N/A ? Yes ? No
Page 6 of 8
PCN Form - Version 1.3 December 10, 2008 Version
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
la. Does the project involve an expenditure of public (federal/state/local) funds or the ® Yes ? No
use of public (federal/state) land?
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 ? Yes ® No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
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: N/A
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Welland Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards, ? Yes ®No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b. Is this an after-the-fact permit application? ? Yes ® No
2c. If you answered. "yes" to one or both of the above questions, provide an explanation of the violation(s): N/A ,• .
3. ' Cumulative Impacts (DWQ Requirement) `!' ` ^`^ a
3a. Will this project (based on past and reasonably anticipated future impacts) result in
El Yes No
®
additional development, which could impact nearby downstream water. quality.?
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.
N/A
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.
N/A '

Page 7 of 8
PCN Form - Version 1.3 December 10, 2008 Version
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or ? Yes No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act ? Yes ® No
impacts?
E] Raleigh
5c. If yes, indicate the USFWS Field Office you have contacted.
? Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
http://www,fws.gov/nc-es/es/countyfr.htmi and NC Natural Heritage Program Database, Element Occurrences
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish ? Yes ®No
habitat?
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat7
http://ocean.floridamarine.org/efh coral/ims/viewer.htm
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
-
El Yes ® No
or properties significant in <
status (e.g., National Historic Trust designation „
North Carolina history and archaeology)?
71b. What data sources did you use to determine whether your site would, impact historic or archeological resources?
HPO's historic layer using GIS ArcView database
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain? ? Yes ® No
81b. If yes, explain how project meets FEMA requirements: N/A
8c. What source(s) did you use to make the floodplain determination? htto://www.ncfloodmaps.com/

J. W. Bowman, P.E. (//nQ ,
I 04/30/10
Applicant/Agent's Printed Name Applicant/Agent's Signa
leter j
(Agent's signature is valid only If an authorization romthe applicant Date
is provided.)

Page 8 of 8
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