20030783 Ver 1_Complete File_20030625

Michael F. Easley, Governor
??F INATp, William G. Ross Jr., Secretary
pG North Carolina Department of Environment and Natural Resources
-O l Alan W. Klimek, P.E., Director
r Di-ision of Water Quality
Coleen H. Sullins, Deputy Director
t? Division of Water Quality
DWQ Project No.: 3 y7P? 3 County: Applicant: C o T
Project Name: ,? ?G E •_ ?T - 5e i7D?'
Date of issuance of 401 Water Quality Certification:
Certificate A Completion
Upon completion of all work approved within the 401 Water Quality Certification and Buffer Rules, and any
subsequent modifications, the applicant is required to return this certificate to the 401/Wetlands Unit, North
Carolina Division of Water Quality, 1621 Mail Service Center, Raleigh, NC, 27699-1621. This form may be
returned to DWQ by the applicant, the applicant's authorized agent, or the project engineer. It is not
necessary to send certificates from all of these.
Applicant's Certification
, ,L, f.?-GL ar-2 , hereby state that, to the best of my abilities, due care and
I,
diligence was used in the observation of the construction such that the construction was observed to be built
within substantial compliance and intent of the 401 Water Quality Certification and Buffer Rules, the
approved plans and?jpecificatio , s, other supporting materials.
Date:
Signature:
Agent's Certification
I, , hereby state that, to the best of my abilities,,due care and as observed diligence was used in the observation nteof the nt construction such
401 Water Qua ty Certif cat onwand Buffer Rules, bthuilt
within substantial compliance and
approved plans and specifications, and other supporting materials.
Date:
Signature:
if this project was designed by a Certified Professional
as a duly registered Professional (i.e.,
I,
Engineer, Landscape Architect, Surveyor, etc.) in the State of North Carolina, having been authorize to the
state , to
used in the project, for
observe (periodically, week) full time) h construction
on oft he co st uction such hat the
the best of my abilities, due care and diligence was
construction was observed to be built within substantial compliance and intent of the 401 Water Quality
Certification and Buffer Rules, the approved plans and specifications, and other supporting materials.
Signature:
Registration No.
N. C. Division of Water Quality, 401 Wetlands Certifii'e „ o nit,
1650 Mail Service Center, Raleigh NC 27699-1650 Ejddress)
2321 Crabtree Blvd., Raleigh, NC 27604-2260 (Location)a
[phone] (phone), 919-733-6893 (fax), (httpJ/h2o.enrst3te wetlands
a?.e
Date

F Michael F. Easley, Governor
WA_
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P. E. Director
Division of Water Quality
-? Coleen H. Sullins, Deputy Director
Division of Water Quality
July 18, 2003
Catawba County
DWQ Project No. 030783
Emergency Repair of SR 1704
APPROVAL of 401 Water Quality Certification with Additional Conditions
Mr. M. L. Holder, P.E.
Division Engineer
N. C. Department of Transportation
Post Office Box 47
Shelby, North Carolina 28151-0047
Dear Mr. Holder:
You have our approval, in accordance with the attached conditions and those listed below, to repair 20 linear feet of an
unnamed tributary to Lyle Creek in order to make an emergency repair to a culvert on SR 1709 in Catawba County. The
NC Division of Water Quality understands that this project was constructed in accordance with the after-fact application
dated June 20, 2003 (received June 25, 2003). NC Division of Water Quality staff reviewed the repair work on July 15,
2003 and were satisfied with the work performed to stabilize the bank.
After reviewing your application, we have decided that this fill is covered by General Water Quality Certification No. 3404
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 2H .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. NCDOT shall implement Best Management Practices for the Protection of Surface Waters (NCVDOT March
1997).
2. All culverts 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 widening of the streambed). Existing stream dimensions
(including the pattern and profile) are to be maintained above and below locations of culvert extensions. The culvert
shall be designed to allow for fish and other wildlife movement as well as prevent headcutting of the streams.
3. The use of riprap for bank stabilization is to be minimized; rather, native vegetation is to be planted when practical.
If riprap is necessary, it must be limited to the stream bank above the high water mark. Riprap shall not be placed
in the stream bottom.
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. All constructed stormwater conveyance outlets shall be directed to flow in a diffuse manner at non-erosive
velocities through the entire protected stream buffers without re-concentrating. If this is not possible it
be necessary to provide stormwater facilities.
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone] Customer Service
1-877-623-6748
6. The presence of equipment in the channels must be minimized. Under no circumstances must 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.
7. Upon completion of the project, the NCDOT or its authorized agent 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. Please include photographs of
the site.
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,
Klimek, P.E,
Attachments
cc: Wilmington District Corps of Engineers
Steve Lund, USACE Asheville Field Office
Trish Simon, Division Environmental Officer
Mooresville Regional Office
Mike Parker, NCDWQ Asheville Regional Office
Central Files
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone]
f
Customer Service
1-877-623-6748
MEMORANDUM
TO: John Dorney Regional Contact:
Non-Discharge Branch WO Supervisor:
Date:
SUBJECT: WETLAND STAFF REPORT AND RECOMMENDATIONS
Facility Name NCDOT - SR 1704
Project Number 03 0783
Recvd From DOT
Received Date 6/25/03 Recvd By Region
Project Type
Region Mooresville
Certificates Stream Stream Impacts (ft.)
Permit Wetland Wetland Wetland Stream Class Acres Feet ME
Type Type Impact Score Index Prim. Supp. Basin Req. Req.
20.00
14 F- P Y O N F__ 11-76 wSIV ?- 30,832. F- F- F F_
P77-0 -?
Mitigation Wetland
MitigationType Type Acres Feet
Is Wetland Rating Sheet Attached? O Y *N Did you request more info? O Y *N
Have Project Changes/Conditions Been Discussed With Applicant? O Y O N
Is Mitigation required? O Y OQ N
Provided by Region: Latitude (ddmmss) 354557
Recommendation: O Issue # Issue/Cond O Deny
Longitude (ddmmss) 811003
Comments:
During a recent rainfall event the existina culvert was washed out. DOT proposed and has
replaced the old culvert with a new culvert extending the culvert 10 feet and adding 5 feet of rip rap_
on the inlet and outlet sides. Also, a new concrete headwall was construced re ip acing the old
concrete bag head wall.
County CATAWBA
County2
cc: Regional Office
Central Office Page Number 1
_ FILE COPY
STATE of NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY LYNDO TIPPETT
GOVERNOR SECRETARY
030783
MEMO TO: John Dorney, DENR/DWQ/401/Wetlands Unit C
FROM: Trish Simon, Division 12 Environmental Officer
DATE: June 20, 2003
SUBJECT: Pre-Construction Notification/401 Automated Payment
*UDS/401 68DUp
Jul `
ERQ04u7?sC
Enclosed are seven copies of a pre-construction notification for a NCDOT project in
Catawba County for your review.
Project information for the 401 Automated Payment Procedure
• Work order number: 150463-55120005-12.B201811-3855
• TIP #: Not Applicable
• Project Category: $200.00 Fee
is
Pq yM?N
D
Post Office Box 47 Shelby, North Carolina 28151-0047
x ? x',
+: -
COPI
ILI
o
.Q??. 3 0 7 83
STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY P.O. BOX 25201, RALEIGH, N .C. 27611-5201 LYNDO TIPPETT
GOVERNOR
P.O. BOX 47, 1710 East Marion Street
Shelby, N. C. 28151-0047
June 20, 2003
Mr. John W. Hendrii NCDOTT Projects
US Army Corp of Engineers
Asheville Regulatory Field Office
151 Patton Avenue, Room 208
Asheville, N. C. 28801-5006
Dear Mr. Hendrix:
SECRETARY
WETLANDS/401 GROUP
JUN z ?5 2003
OTERQUALITYSEC a
Per our telephone conversation on June 18, 2003, the North Carolina Department of
Transportation, Division of Highways, request the issuance of a Section 404 Permit, Nationwide
Permit #14, Maintenance and #33, Temporary Construction, Access, and Dewatering.
COUNTY: Catawba
LOCATION: SR 1704, north of Conover
STREAM: Unnamed tributary to Lyle creek, WS-IV Watershed (from Bakers
Creek to US Hwy 64/70), Catawba River Basin
PROJECT DESCRIPTION: The project consists of the replacement of a 60' long, 72" CMP
with a 70' long, 112"x 75" CMP with inlet concrete headwall. The original pipe was washed out
due to the flooding on 6/16/03. This project is considered an emergency project and construction
is to commence immediately. There will be a minimal increase in pipe length with minimal
additional impacts. Five feet of riprap will be used at the inlet and outlet for structure protection
and stabilization. Temporary cofferdams will be used to manage the water course during
construction. Upon project completion, the area impacted by the temporary cofferdams will be
restored to pre-construction conditions. I have enclosed a PCN application, a sketch of activities,
and location maps relative to the project.
The proposed project is located in Class WS-IV watershed; however, it is not located within'h
mile of the critical watershed area nor is the road functionally classified as a rural or urban arterial.
Hazardous spill basins are not required. Enclosed is the NCDOT hazardous spill basin checklist.

'r
Mr. John Hendrix
SR 1704- Page Two
June 20, 2003
A review of the Natural Heritage information for the threatened species listed for Catawba
County, the dwarf-flowered heartleaf (Hexastylis nan flora) revealed no known sites in the
vicinity of the project area. A survey for these species was conducted on June 19, 2003 in the
vicinity of the proposed project. It was determined that this neither species nor suitable habitat
were located in the project area; therefore, no impact on this species is anticipated. A review of
the available information from the National Register of Historic Places was also conducted. No
historic sites were affected by the project.
Your earliest consideration for this request would be greatly appreciated. Should you have any
questions, please call me at 704-480-9020.
Respectfully yours,
M.L. Holder, P.E.
Division Engineer
Twelfth Division
ar y'??
Trish Simon
Division 12 Environmental Officer
Enclosures
cc: Mr. Nfichael L. Holder, P.E., Division Engineer
Mr. Dan Holderman, P.E. , Division Bridge Engineer
Mr. Mike Parker, DENR, DWQ, Asheville Regional Office
Mr. John Dorney, DENR, DWQ, 401/Wetlands Unit
Mr. Neil Trivette, Roadside Environmental Field Engineer
File
Office Use Only: Form Version October 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.
I. 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: Nationwide Permit #14, 933
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: ?
H. Applicant Information
1. Owner/Applicant Information
Name: Mike Holder NCDOT
Mailing Address: P.O. Box 47
Shelby, NC 28151
Telephone Number: 704480-9020 Fax Number: 704-480-5401
E-mail Address:
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: Trish Simon
Company Affiliation: NCDOT
Mailing Address: P.O. Box 47
Shelby, NC 28151
Telephone Number: 704-480-9044 Fax Number: 704480-5401
E-mail Address: [e-mail]
Page 1 of 8
M. 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.
Name of project: Emergency pipe Replacement on SR 1704 , Catawba County; Pike
washed out in storm of 6/16/03.
2. T.I.P. Project Number or State Project Number (NCDOT Only): 12B.201811
3. Property Identification Number (Tax PIN): NCDOT Right of way
4. Location
County: Catawba Nearest Town: Conover
Subdivision name (include phasellot number): NA
Directions to site (include road numbers, landmarks, etc.): HM ,y 16 north from Conover.
Turn right onto SR 1704 and proceed -0.4 miles to project site.
5. Site coordinates, if available (UTM orLat/Long): 35°45'57'N/81°10'03W
(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:
Pipe on a paved secondary road
7. Property size (acres): 0.15 acres NCDOT right of way
8. Nearest body of water (stream/river/sound/ocean/lake): UT to Lyle Creek (From Bakers
Crk to US Hwy 64/70), WS-IV Watershed
9. River Basin: Catawba
(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/mgps/.)
Page 2 of 8
10. Describe the purpose of the proposed work: This emer engy project consists of replacing a
pipe which was washed out in the storm of 6/16/03 (was 72", 60-foot CMP) with a 112" x
75", 70 foot CNIP with inlet concrete headwall.
11. List the type of equipment to be used to construct the project: A trackhoe will be used
for excavation and placement of ripra.
12. Describe the land use in the vicinity of this project: The surrounding area is mostly
residential yards and pastureland.
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 future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application:
No future permit requests anticipated.
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
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: NONE
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***

Page 3 of 8
* 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) Hood 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 httv://wwv.fema.gov.
*** List a wetland type that best describes wetland to be impacted (e.g., ticshwater/saltwater marsh, forested wetland, beaver pond.
Carolina Bay, bog, etc.)
List the total acreage (estimated) of existing wetlands on the property: 0
'? gtrAam ImnactS inchtding all intermittent and perennial streams
Stream
Impact Site
Length of Impact Average Width Perennial or
Number Type of Impact*
(linear feet) Stream Name** of Stream Intermittent?
(indicate on Before Impact (please specify)
map)

i Pipe culvert
(increase in pipe
10 feet UT to Lyle
8 feet
Perennial
Creek
length)
Placement of riprap 5 feet (inlet)
I on streambank for 5 feet (outlet)
structure protection Total= 10 feet
1 Temporary coffer 20 feet
dams
List each impact separately and identify temporary impacts. Impacts include, but are not limmted to: culverts and associate np-rap,
dams (separately list impacts due to both structure and flooding), relocation (include liner feet betbre and after, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, exc.), excavation, ditching/straightaiing, exc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated strauns nnust be included.
" Steam names can be found on USGS topographic maps. It a streaun has no nalne, 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
w-%A-Nv.usgs.2ov. Several internee sites also allow direct download and printing of USGS maps (e.g., a%tu.tonozone.coni,
?e???r.matx uest.com. etc.).
Cumulative impacts (linear distance in feet) to all streams on site: Increase in pipe length =
10 feet Total Riprap used on stream bank for structure protection = 10 feet, Total
temporary cofferdam and stream diversion impacts = 20 feet.
Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U.S. NO OPEN WATER IMPACTS
Open Water Impact Area of
Name Wat Type of Waterbody
Site Number Type of Impact* Impact )
(if applicable) (lake, pond, estuary, sound,
(indicate on ma) (acres) bey, ocean, etc.)

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
Page 4 of 8
4. Pond Creation NO 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.
Pipe washed out due to flooding on 6/16/03 There will be only a minimal increase in pipe
length (10 few with minimal additional stream impacts Temporary cofferdams will be used and
the stream will be pumped around the work site during construction.
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/ncwetiands/strmgide.html.
Page 5 of 8
I . Provide a brief description of the proposed mitigation plan. The description s.
as much information as possible, including, but not limited to: site location (att
and/or map, if offsite), affected stream and river basin, type and amount (acrea
of mitigation proposed (restoration, enhancement, creation, or preservation),
preservation mechanism (e.g., deed restrictions, conservation easement,
description of the current site conditions and proposed method of construction.
a separate sheet if more space is needed.
IMPACTS < 150 FEET MITIGATION NOT ANTICIPATED
2. Mitigation may also be made by payment into the North Carolina Wetland
Program (NCWRP) with the NCWRP's written agreement. Check the box i
you would like to pay into the NCWRP. Please note that payment into the NC
reviewed and approved before it can be used to satisfy mitigation requirement
will be notified early in the review process by the 401/Wetlands Unit if pay
NCWRP is available as an option. For additional information regarding tl
process for the NCWRP, check the NCWRP website at http://h2o.enr.state.nc.us/xy1
use of the NCWRP is proposed, please check the appropriate box on page thre
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 (fede;
land?
Yes ® No ?
If yes, does the project require preparation of an environmental document PL
requirements of the National or North Carolina Environmental Policy Act (I`
Note- If you are not sure whether a NEPA/SEPA document is required, c?
coordinator at [phone] to review current thresholds for environmental docut
Yes ? No
If yes, has the document review been finalized by the State Clearinghouse? If so, 1
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
required state and local buffers associated with the project. The applicant mus,
justification for these impacts in Section VII above. All proposed impacts must bE
and must be clearly identifiable on the accompanying site plan. All buffers must l
Page 6 of 8
map, whether or not impacts are proposed to the buffers. CvncsPontles??ran dw DWQ
Regional Office may be included as appropriate. Photographs may Aso be included at the
applicant's discretion. -
Will the project impact protected riparian buffers identified within 15A NCAC 213 .0233
(Meuse), 15A NCAC 213 .0259 (Tar-Pamlico), 15A NCAC 213 .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. -ff +effia
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
' "Lone 1 extends out 30 teet perpendicular from near otmx of cnannu; [_onc su
additional 20 Feet from the edge of _one 1.
Ifhuffer mitigation is required, please discuss what type of mitigation is proposed (i.e' l1nnation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservations
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or.0260.
XIt 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.
No additional impervious surface is proposed in this project
XH. 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.
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 ?
*Due to emergency nature of the project, the pipe must be replaced immediately.
Page 7 of 8
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).
NA
-01
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Page 8 of 8
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NCDOT
HAZARDOUS SPILL BASIN CHECKLIST
Division: 1Z County: Project ID: 12 6, ? oje l l
River Basin: G?73w? Bridge No: i E _
C1st.J;U?r» ? ? ? url N? y
Route: z7L 17ad Stream: 70 Z.y4.45 Water Quality Criteria: ?„1.5 7J'

Yes No
Stream Crossing Blue Line On USGS (r r
ORW r_ Ev-
WSI r r_?
WS II,III OR IV, Crossing Within 0.5mi of W. S. Critical Area r r?
Roadway Criteria:
Route Designation-
Additional Site Information:
Yes No
Arterial Urban r r?
Arterial Rural r r?
Yes No
Is a Hazardous Spill Basin Required? C E?
Criteria Based Upon NCDOT "Best Management Practices for the
Protection of Surface Waters" (March, 1:997).