20100635 Ver 1_Application_20100802

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Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Pre-Construction Notification C Form
A. Applicant Information
1. Processing
la. Type(s) of approval sought from the
Corps:

Sedion 404 Permit E] Section 10 Permit
I
1 b. Specify Nationwide Permit (NWP) number: 3 or General Permit (GP) number:
1c. Has the NWP or GP number been verified by the Corps? ? Yes ® No
1d. Type(s) of approval sought from the DWQ (check all that apply):
® 401 Water Quality Certification - Regular ? Non-404 Jurisdictional General Permit
? 401 Water Quality Certification - Express ® Riparian Buffer Authorization
le. Is this notification solely for the record
because written approval is not required? For the record only for DWQ 401
Certification:
? Yes ® No For the record only for Corps Permit:

® 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 ® No
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below. ? Yes ® No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ? Yes ® No
2. Project Information

2a.
Name of project: SR 1711,Worthington Road,Pitt County Addition of a Center Turn Lane in Front of D.H.
Conley High School Widening and Resurfacing from NC 43 to 2500' West of NC 43.
WBS Element Number 40466
2b. County: Pitt
2c. Nearest municipality / town: Winterville
2d. Subdivision name: N/A
2e. NCDOi only, T.I.P. or state
project no: N/A
3. Owner Information
3a. Name(s) on Recorded Deed: North Carolina Department of Transportation
3b. Deed Book and Page No. N/A %
3c. Responsible Party (for LLC if
applicable): WA
3d. Street address: 105 Pactolus Highway NC 33 P.O. Box 1587
3e. City, state, zip: Greenville, NC 27835
3f. Telephone no.: 252-830-3490
3g. Fax no.: 252-830-3341
3h. Email address: [e-mail]
Page 1 of 11
PCN Form - Version 1.3 December 10, 2008 Version
4. Applicant Information (If different from owner)
4a. Applicant is: ? Agent ® Other, specify: Division 2 Environmental Officer
4b. Name: Jay B. Johnson
4c. Business name
(if applicable):
North Carolina Depratment of Transportation
4d. Street address: P.O. Box 1587
4e. City, state, zip: Greenville, NC 27835
4f. Telephone no.: 252-830-3490
4g. Fax no.., 252-830-3341
4h. Email address: [e-mail]
5. Agent/Consultant Information (if applicable)
5a. Name: N/A
5b. Business name
(if applicable):
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:
Page 2 of 11
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): SR 1711,Worthington Road, Pitt County Addition of a
Center Turn Lane in Front of D. H. Conley High School
Latitude: N 35.531839 Longitude: - W
1b. Site coordinates (in decimal degrees): 77.322305
(DD.DDDDDD) (-DD.DDDDDD)
1c. Property size: N/A acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to Un-Named Tributary of Indian Well Swamp
proposed project:
2b. Water Quality Classification of nearest receiving water. C;Sw;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:
SR 1711,Worthington Road is an paved secondary state highway. Residential Development,and D.H. Conley High
School dominate the landscape.
3b. List the total estimated acreage of all existing wetlands on the property:
0 Square Feet of 404 Wetland Impacts For The Center Turn Lane
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
60' This site is part of a longer adjacent stream system
3d. Explain the purpose of the proposed project:
3e. Describe the overall project in detail, including the type of equipment to be used:
SR 1711,Worthington Road is to be Widened and resurfaced From NC 43 to 2500' West of NC 43 with a Center Turn
Lane in Front of D.H. Conley High School.
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:
4b. 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: NCDWQ
Name (if known): Garcy Ward Other.
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
May,2009
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.
Page 3 of 11
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.
C. Proposed Impacts Inventory
1. Impacts Summary
I a. 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
W1 ? P ? T ? Yes ? Corps
? No ? DWQ
W2 ? P ? T ? Yes ? Corps
? No ? DWQ
W3 ? P ? T ? Yes ® Corps
? No ® DWQ
W4 ? P ? T ? Yes ? Corps
? No ? DWQ
W5 ? P ? T ? Yes ? Corps
? No ? DWQ
W6 ? P ? T ? Yes El Corps
? No ?DWQ
2g. Total wetland impacts None
2h. Comments: No 404 Wetland Impacts
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a. 3b. 3c. 3d. 3e-
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 - non-404, width (linear
Temporary (T) (INT)? other) (feet) feet)
S1 ? P ? T ? PER ? Corps
? INT ? DWQ
S2 ? P ? T ? PER ? Corps
? INT ? DWQ
S3 ? P ? T ? PER ? Corps
? INT ? DWQ
S4 ? P ? T ? PER ? Corps
? INT ? DWQ
S5 ? P ? T ? PER ? Corps
? INT ? DWQ
S6 ? P ? T ? PER ? Corps
? INT ? DWQ
3h. Total stream and tributary impacts 0 LF
3i. Comments: 0 Linear Feet of Stream Impacts
Page 5 of 11
PCN Form -Version 1.3 December 10, 2008 Version
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.
Open water
impact number-
Permanent (P)
or Temporary 4b.
Name of waterbody
(if applicable) 4c.

Type of impact 4d.

Waterbody type 4e.

Area of impact (acres)
01 ?P?T
02 ?P?T
03 ?P?T
04 ?P?T
4E Total open water impacts None
4g. Comments: None
5. Pond or Lake Construction
If pond or lake construction proposed, then complete the chart below.
5a.

Pond ID 5b.

Proposed use or purpose of 5c.
Wetland Impacts (acres) 5d.
Stream Impacts (feet) 5e.
Upland
(acres)
number pond
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1
P2
5r. Total None
5g. Comments: None
5h. Is a dam high hazard permit required?
? Yes ? No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
Page 6 of 11
PCN Form - Version 1.3 December 10, 2008 Version
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.
6a.
® Neuse ?Tar-Pamlico ? Other. None
Project is in which protected basin? ? Catawba ? Randleman
6b. 6c. 6d. 6e. 6f. 6g.
Buffer impact
number- Reason Buffer Zone 1 impact Zone 2 impact
Permanent (P) for impact Stream name mitigation (square feet) (square feet)
or Temporary required?
Pavement
B1 ®P ? T Widening Un-Named Tributary of Indian ? Yes 520 Sq. Ft. 355 Sq
Ft

and Ditch
Well Swamp
® No .
.
Relocation
Pavement
B2 ®P ? T Widening Un-Named Tributary of Indian ? Yes 485 Sq. Ft. 310 Sq
Ft

and Ditch
Well Swamp
® No .
.
Relocation
Pavement
B3 ®P ? T Widening Un-Named Tributary of Indian ? Yes 1250 Sq. Ft. 810 Sq
Ft

and Ditch
Well Swamp
® No .
.
Relocation
6h. Total buffer impacts
6i. Comments: See Page 6-A For Total Buffer Impacts
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
There are No 404 Wetland Impacts for this Project; Therefore,The Wetland Impacts have been minimized to the greatest
extent feasible, with minimal impacts occurring on the project
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Use of existing roadway to operate construction equipment; no equipment will enter wetlands.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for ? Yes ® No
impacts to Waters of the U.S. or Waters of the State?
2b. If yes, mitigation is required by (check all that apply): ? DWQ ? Corps
? Mitigation bank
2c. If yes, which mitigation option will be used for this project? ? Payment to in-lieu fee program
? Pernittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter) Type Quantity
Page 7 of 11
PCN Form - Version 1.3 December 10, 2008 Version
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.
6a.
® Neuse ?Tai-Pamlico ? Other: None
Project is in which protected basin? ? Catawba ? Randleman
6b. 6c. 6d. 6e. 6f. 6g.
Buffer impact
number- Reason Buffer Zone 1 impact Zone 2 impact
Permanent (P) for impact Stream name mitigation (square feet) (square feet) _
or Temporary required?
B4 Fill

B1 ®P ? T Roadway
Widening Un-Named Tributary of Indian ? Yes
1905 Sq. Ft.
1270 Sq
Ft

and Ditch
Well Swamp
No .
.
Relocation
B2 ?P?T ?Yes
? No
B3 ?P?T ?Yes
? No
6h. Total buffer impacts 4160 Sq. Ft. 2745 Sq. Ft.
6i. Comments:
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
2. Compensatory Mitigation for Impacts to Waters of the.U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for ? Yes ? No
impacts to Waters of the U.S. or Waters of the State?
2b. If yes, mitigation is required by (check all that apply): ? DWQ ? Corps
? Mitigation bank
2c. If yes, which mitigation option will be used for this project? ? Payment to in-lieu fee program
? Pernittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter) Type Quantity
7A o F
Page-6 0T-f-
PCN Form - Version 1.3 December 10, 2008 Version
3c. Comments:
4. Complete if Making a Payment to ln41eu Fee Program
4a. Approval letter from in-lieu fee program is attached. ? Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature: ? warm ? cool Elcold
4d. Buffer mitigation requested (DWQ only): square feet
4e. Riparian wetland mitigation requested: acres
4f. Non-riparian wetland mitigation requested: acres
4g. Coastal (tidal) wetland mitigation requested: acres
4h. Comments:
5. Complete if Using a Perrnittee Responsible Mitigation Plan
5a. If using a pennittee responsible mitigation plan, provide a description of the proposed mitigation plan.
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 Z No
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.

Zone 6c.
Reason for impact 6d.
Total impact
(square feet)
Multiplier 6e.
Required mitigation
(square feet)
Zone 1 3 (2 for Catawba)
Zone 2 1.5
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,
pennittee responsible riparian buffer restoration, payment into an approved in-lieu fee fund).
N/A
6h. Comments:
Page 8 of 11
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 N Yes ? No
within one of the NC Riparian Buffer Protection Rules?
lb - If yes, then is a diffuse flow plan included? If no, explain why.
Comments: Grass Swales and Special Sediment Control Fence will be used to treat g Yes ? No
Stormwater Runoff from the road. Wattles will be used to prevent sediment from
entering into the stream.
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project? N/A Roadway/Bridge Project %
2b. Does this project require a Stormwater Management Plan? N Yes ? No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
Grass Swales and Special Sediment Control Fence will be used to treat Stormwater Runoff from the road. Wattles will be
used to prevent sediment from entering into the stream.
? 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? N/A
? Phase II
3b. Which of the following locally-implemented stonnwater management programs El NSW
? USMP
apply (check all that apply): ? Water supply Watershed
? Other: N/A
3c. Has the approved Stormwater Management Plan with proof of approval been ? Yes N No
attached?
4. DWQ Stormwater Program Review
? Coastal counties
? HQW
4a. Which of the following state-implemented stormwater management programs apply ? ORW
(check all that apply):
? Session Law 2006-246
N Other. NPDES Permit
4b. Has the approved Stormwater Management Plan with proof of approval been
attached? ? Yes N No
5. DWQ 401 Unit Stormwatar Review
5a. Does the Stormwater Management Plan meet the appropriate requirements? ? Yes ? No
5b. Have all of the 401 Unit submittal requirements been met? ? Yes ? No
Page 9 of 11
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
ED Yes

? No
use of public (federal/state) land?
1b. 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:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 2H.0500), Isolated
Wetland Rules (15A NCAC 21-1.1300), 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):
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in ?Yes [OD 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.
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 10 of 11
PCN Form - Version 1.3 December 10, 2008 Version
S. 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?
5c. If yes, indicate the USFWS Field Office you have contacted. F] Raleigh
? Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
On-Site Inspection
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? ? Yes ® No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
On-Site Inspection
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 ? Yes No
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
NCSHPO
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain? ? Yes ® No
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination? FEMA FIRM Maps
Jay B. Johnson July 23, 2010
Applicant/Agents Printed Name Appl' n A e Signature Date
(Agents signature rs val' my a a oration letter from the applicant

Page 11 of 11
PCN Form - Version 1.3 December 10, 2008 Version
I
04/02/2009 13:42
NC STATE HISTORIC PRESERVATION i 912528303352
NO. 123 002
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