20110311 Ver 1_Application_20110405

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o TrJ.I„ JL Corps action ID no.
o?C < DWQ project no.
Form Version 1.3 Dec 10 2068
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 ? Section 10 Permit
I
1b. 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 ® 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:

N Yes ? No
1 f. 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: Proposed pipe replacement; SR 1328 (Charlie Stovall Rd) in extreme NW Granville
County of Hwy 96.
2b. County: Granville
2c. Nearest municipality / town: Oak Hill
2d. Subdivision name: N/A
2e. NCDOT only, T.I.P. or state
project no: 0

3. -%F NJ
Owner Information
3a. Name(s) on.Recorded Deed: NCDOT Division 5
3b. Deed Book and Page No. N/A S` WIN
3c. Responsible Party (for LLC if
applicable): N/A
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 7.3 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 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.
6a.
? 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 (square feet) (square feet)
Temporary T required?
Site ? P ? T ? Yes

Buffer Impact 1
®No NONE NONE

61h. Total buffer impacts NONE NONE
6i. Comments: N/A
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
This pipe will be replaced in the same alignment with a pipe of the same length. Rip rap armoring around the pipe ends and
tie-in points to the existing stream back will be limited only to the amount necessary to ensure long term stability.
1b. 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 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 Z 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
31b. 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: ? warm ? cool ?cold
4d. Buffer mitigation requested (DWQ only): N/A square feet
4e. Riparian wetland mitigation requested: N/A acres
4f. Non-riparian wetland mitigation requested: N/A acres
4g. Coastal (tidal) wetland mitigation requested: 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 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 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
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
1a . 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 replacement 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: NCDOT 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? Granville County
? Phase II
31b. Which of the following locally-implemented stormwater management programs ? NSW
? USMP
apply (check all that apply): ? Water Supply Watershed
? 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
? HQW
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
attached? N/A ? Yes ? No
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements? N/A ? Yes ? No
5b. 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 Wetland 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)
3a. Will this project (based on past and reasonably anticipated future impacts) result in ? 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 a ccordance 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?
?
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, ov/nc-es/es/countvfr.html 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 Habitat?
hftp://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 ? 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?
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
8b. If yes, explain how project meets FEMA requirements: N/A
8c. What source(s) did you use to make the floodplain determination? hftp://www.ncfloodmaps.com/

J. W. Bowman, P.E. q ? 04/04/11

A licanUA ent's Printed Name
pp g Applicant/Agent's Signatur

(Agents signature Is valid only It an authorization le from the applicant
Date
_,.. Is Provided.)
Page 8 of 8
PCN Form - Version 1.3 December 10, 2008 Version
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