20120018 Ver 1_Application_20120106

v
STATE OF NORTH CAROLINA
r�
DEPARTMENT OF TRANSPORTATION ®
BEVERLY EAVES PERDUE EUGENE A Co TI JR
GOVERNOR SECRETARY
January 3 2012
U S Army Corps of Engineers
Wilmington Regulatory Field Office
69 Darlington Avenue
Wilmington North Carolina 28403
ATTENTION Mr Brad Shaver
NCDOT Coordinator
2 0 1 2 0 0 1 8
SUBJECT Nationwide 14 Permit Application for Secondary Road Improvement on SR 1940
Balance Road in Sampson County WBS# 3C 082051 (DWQ Permit Fee $240)
Dear Mr Shaver
Please find enclosed a PCN application from the North Carolina Department of Transportation ( NCDOT) for a
Nationwide 14 permit for the secondary road improvement project on SR 1940 Balance Road in Sampson County
The scope of the project will be to widen, grade dram add base and pave the 0 62 mile of existing unpaved road to
current NCDOT secondary road standards to improve the roadway safety and stability These standards include 20
feet of travel lanes and 5 feet of grassed shoulders on both sides within the 50 feet of right of way Also enclosed are
stream identification forms plans and maps for the issuance of a. jurisdictional determination based on our field
review on September 13 2011 The, jurisdictional forms have been supplied to you electronically
By copy of this letter and enclosures NCDOT is also requesting issuance of 401 Water Quality Certification (WQC)
#3820 from the Division of Water Quality (DWQ) A method of debiting $240 to process the WQC permit request
has been provided as noted in the subject line of this application
If you have any questions or need any additional information, please contact me at [phone]
S erel
onewa j Mais
Division Environmental Officer
Enclosures
cc with attachments
Mr Mason Herndon DWQ (1 copy)
Mr Brian Wrenn DWQ (5 copies)
5501 BARBADOS BLvD CASTLE HAYNE NC 28429
PHONE [phone] FAx [phone]

o�0F W ATF9pG
Uj 9
1 1 > y
1 �Qi 1 0 c
Office Use Only
Corps action ID no
DWQ project no
Form Version 13 Dec 10 2008
Page 1 of 11
PCN Form - Version 13 December 10 2008 Version
Pre - Construction Notification PC Form
A Applicant Information
1
Processing
la
Type(s) of approval sought from the
Corps
®section 404 Permit El Section 10 Permit
1 b Specify Nationwide Permit (NWP) number 14 or General Permit (GP) number
1 c
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
1 e
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
if
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
1h
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes
® No
2
Project Information
2a
Name of project
SR 1940 Balance Road
2b
County
Sampson
2c
Nearest municipality / town
Turkey
2d
Subdivision name
n/a
2e
NCDOT only T I P or state
project no
3C 082051
3
Owner Information
3a
Name(s) on Recorded Deed
NC Department of Transportation
3b
Deed Book and Page No
n/a
3c
Responsible Party (for LLC if
applicable)
n/a
3d
Street address
n/a
3e
City state zip
n/a
3f
Telephone no
n/a
3g
Fax no
n/a
3h
Email address
n/a
Page 1 of 11
PCN Form - Version 13 December 10 2008 Version

4
Applicant Information (if different from owner)
4a
Applicant is
❑ Agent ® Other specify NCDOT Division 3 Engineer
4b
Name
H Allen Pope
4c
Business name
(if applicable)
NC Department of Transportation
4d
Street address
5501 Barbados Blvd
4e
City state zip
Castle Hayne NC 28429
4f
Telephone no
910 341 2000
4g
Fax no
910 675 0143
4h
Email address
n/a
5
AgentlConsultant information (if applicable)
5a
Name
Stonewall Mathis
5b
Business name
(if applicable)
NC Department of Transportation
5c
Street address
5501 Barbados Blvd
5d
City state zip
Castle Hayne NC 28429
5e
Telephone no
910 341 2036
5f
Fax no
910 675 0143
5g
Email address
smathis @ncdot gov
Page 2 of 11
PCN Form — Version 1 3 December 10 2008 Version

B Project Information and Prior Project History
1 Property Identification
la Property identification no (tax PIN or parcel ID)
SR 1940 Balance Road
Latitude 34 8961381 N Longitude
1 b Site coordinates (in decimal degrees)
78 2443211 W
(DD DDDDDD) ( DD DDDDDD)
1c Property size
—3 76 acres
2 Surface Waters
2a Name of nearest body of water (stream river etc) to
UTs to Six Runs Creek
proposed project
2b Water Quality Classification of nearest receiving water
C SW
2c River basin
Cape Fear
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
The site is currently an unpaved road with ditches The general surrounding land use is mostly agricultural with some
woodlands
3b List the total estimated acreage of all existing wetlands on the property
000
3c List the total estimated linear feet of all existing streams (intermittent and perennial) on the property
—110 linear feet
3d Explain the purpose of the proposed project
To improve the existing roadway by bringing it up to NCDOT standards to include paving to provide a better and safer
roadway for citizens and landowners that utilize this facility
3e Describe the overall project in detail including the type of equipment to be used
This project will widen grade drain add base pave and stabilize the existing road to NCDOT secondary road standards
to 20 feet of travel lanes and 5 feet of grassed shoulders using standard road construction equipment
4 Jurisdictional Determinations
4a Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
®Yes F1 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
Name (if known) Stonewall Mathis
I Other NCDOT
4d If yes list the dates of the Corps jurisdictional determinations or State determinations and attach documentation
September 13 2011
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 13 December 10 2008 Version

6 Future Project Plans
6a is this a phased project? ❑ Yes ® No
6b if yes explain
Page 4 of 11
PCN Form — Version 1 3 December 10 2008 Version

C Proposed Impacts Inventory
1 Impacts Summary
la 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
❑ Corps
❑ No
❑ DWQ
2g Total wetland impacts
2h Comments
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
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 — non -404
width
(linear
Temporary (T)
(INT)?
other)
(feet)
feet)
S1 ®P ®T
P is fill T is for
construction
UT to Six Runs Ck
❑ PER
® INT
® Corps
® DWQ
10
P =4
T =10
S2 ®P ®T
P is fill T is for
construction
UT to Six Runs Ck
❑ PER
® INT
® Corps
® DWQ
8
P =4 T =5
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
P =8
T =15
N Comments Total Impacts me perm & temp is 23 feet S1 is at Station 14 +36 S2 is at station 30 +18 on downstream side
Page 5 of 11
PCN Form — Version 13 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
4b
4c
4d
4e
Open water
Name of waterbody
impact number—
(if applicable)
Type of impact
Waterbody type
Area of impact (acres)
Permanent (P) or
Temporary
01 ®P ®T
UT to Six Runs Ck
P is fill T is for construction
Tributary
P =0 001 T =0 001
02 ❑P ❑T
03 ❑P ❑T
04 ❑P ❑T
o
4f Total open water impacts
0 002
4g Comments This is the tributary on the upstream side at station 30 +18
5 Pond or Lake Construction
If pond 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
(acres)
number
of pond
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1
P2
5f Total
5g Comments
5h Is a dam high hazard permit required
❑ Yes ❑ No If yes permit ID no
51 Expected pond surface area (acres)
5j Size of pond watershed (acres)
5k Method of construction
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 any 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
Buffer
Zone 1 impact
Zone 2 impact
Permanent (P) or
for
Stream name
mitigation
(square feet)
(square feet)
Temporary
impact
required
B1 ❑P ❑T
El Yes
❑ No
B2 ❑ P ❑ T
❑ Yes
❑ No
B3 ❑P ❑T
El Yes
❑ No
6h Total buffer impacts
61 Comments
Page 6 of 11
PCN Form — Version 1 3 December 10 2008 Version

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 pipe lengths and additional associated fill are minimized to only that needed for safety and road construction
1 b Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques
Strict implementation of sediment and erosion control BMPs will be utilized to protect waters of the US
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
3b Credits Purchased (attach receipt and letter)
Type
Quantity
3c Comments
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
linear feet
4c If using stream mitigation stream temperature
❑ warm ❑ cool ❑cold
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 Permittee Responsible Mitigation Plan
5a If using a permittee responsible mitigation plan provide a description of the proposed mitigation plan
Page 7 of 11
PCN Form — Version 1 3 December 10 2008 Version

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
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
15
6f Total buffer mitigation required
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)
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
1 a 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
2 Stormwater Management Plan
2a What is the overall percent imperviousness of this project?
-40%
2b Does this project require a Stormwater Management Plan?
® 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
NCDOT s BMPs for Construction and Maintenance Activities will be utilized to manage stormwater runoff during
construction Ditch side slopes will be flattened to the maximum extent possible to promote shallow non erosive flows
and infiltration See the attached Water Quality Classification Request Form from Mike Lawyer NCDWQ FRO
❑ 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?
❑ Phase II
3b Which of the following locally implemented stormwater management programs
❑ NSW
El
apply (check all that apply)
El ❑ Water Supply Watershed
❑ Other
3c Has the approved Stormwater Management Plan with proof of approval been
❑ Yes ❑ 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
❑ Other
4b Has the approved Stormwater Management Plan with proof of approval been
❑
❑ Yes No
attached?
6 DWQ 401 Unit Stormwater 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
® Yes
❑ No
use of public (federal /state) land?
lb
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
❑Yes
El No
letter)
Comments
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)
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 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

6 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?
USFWS website was utilized for Sampson County Potential wood stork and pondberry habitat namely stream and
tributary areas and the adjacent floodplains are present on the project neither of these species is thought to be present
on the project Finding of may affect not likely to adversely affect is recommended
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?
NOAA website
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?
NCDOT Cultural Review for both please see attached documentation
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? NC Floodmaps website
4
January 3
Stonewall Mathis
i
2012
Applicant/Agents Printed Name
Date
Applicant/Agent s Signature
(Agents signature is valid only if an authorization letter from the applicant
is provided
Page 11 of 11
PCN Form — Version 1 3 December 10 2008 Version

SR 1940 Balance Road Vicinity Map
Grade, Drain, Base, and Pave
Sampson County
a
1147 ountG\\eaa
a
Q 4 =
o Powell Rd
CO •1939
R
peacson Farm l n
ID Ao
M SR 1940 Balance Road
p o
a
�a
o�
�G
Moseley
Ave 1146 = William on Rd
v o�
M
La
N
•
N
�a
0
Q � Q 1945
0 8001,600 3,200 4,800 6,400
Feet

SR 1940 Balance Road
Grade, Drain, Base, and Pave
Sampson County
cem
O
T
SR 1940 Balance Road
en William
1146
Taylors
1
•' 1. } J iiyi, 5
N
Picnic
0 5001,000 2,000 3,000 4,000
Feet

SR 1940 Balance Road Lidar Image
Grade, Drain, Base, and Pave
Sampson County
G
v � �
0
m � �
� v N
- o
SR 1940 Balance Road a
CD
M.
r u
° o
r
n'S
1146 w1r,
� oa
m
Ol
m
O
H
7g 4
so
�a
I o \3
u � '
q,
0 5001,000 2,000 3,000 4,000
Feet

SR 1940 Balance Road Aerial Image
Grade, Drain, Base, and Pave
Sampson County
0 5001,000 2,000 3,000 4,000
Feet

Nf 111W(1 CtrPam TApntifientfion Form Verman 4 11 5--I1caw. @0 P-t4 e^ )443b
Date rf 2 2 / (I
Project/Site SR 11" 1a 14nce V
Latitude 3 t1 $ q (.13 81 ° nl
Evaluator –r4 o �It M-41, 1
County s a— re,
Longitude 4 3 Z t I w
Total Points
Steam least 21 s
Stream Deteon (circle one)
Other
►s at intermittent
Ephemeral Intennitten Perennial
e g Quad Name
if 2 19 or perennial if 2:30
2
3
A Geomorphology (Subtotal = 13 5
Absent
Weak
Moderate
Stro g
18 Continuity of channel bed and bank
0
1
2
3
2 Sinuosity of channel along thalweg
0
1
2
3
3 In channel structure ex nffle -pool step -pool
rl pie pool sequence
0
1
2
3
4 Particle size of stream substrate
0
1
/-23
3
5 Active /relict floodplain
0
1
2
3
6 Depositional bars or benches
0
rj3
2
3
7 Recent alluvial deposits
0
1
2
3
8 Headcuts
15
1
2
3
9 Grade control
ro
05
1
15
10 Natural valley
05
1
5
11 Second or greater order channel
o = 0
Yes = 3
a artificial ditches are not rated see discussions in manual
R W Arnlr% 1Q11Kfnf1M1 = (- 4�7 i
V 11 41 vIV
12 Presence of Baseflow
0
1
2
3
13 Iron oxidizing bacteria
--Co
1
2
3
14 Leaf litter
15
'I
7-D-7-
05
0
15 Sediment on plants or debris
0
05
2
15
16 Organic debris Imes or piles
0
CO 5
1
15
17 Soil based evidence of high water table?
No = 0
es = 3
f` 12lnit% /CI hfnf!Ml = I C i
v vlvw
18 Fibrous roots in streambed
2
1
0
19 Rooted upland plants in streambed
3
2
1
0
20 Macrobenthos (note diversity and abundance)
0
1
2
3
21 Aquatic Mollusks
0�
2
3
22 Fish
0
05
1
15
23 Crayfish
0
05
1
15
24 Amphibians
0
05
1
15
25 Algae
0
0 5
1
15
26 Wetland plants in streambed
FACW = 0 75 OBL = 1 5
er =
0
perennial streams may also be identified using other methods See p 35 of manual
Notes
Sketch
E1d
TN 1 4 1 N

NC DWO Stream Identification Form Version 411 A{ S�a� .- 30 +)S, '' rear s,d8
Date *j I 121, I
Project/Site iR M 40 %14.,6c U
Latitude 3y 61548 I N
Evaluator -54e" NA s
County Sa,,,, fls o-.
Longitude is 2419914 *W
Total Points
etermmatton (circle one)
Other
Stream is at least intermittent j s
if 2 19 or perennial if Z 30
Ephemera Intermittent Perennial
e g Quad Name r kg
Tie
A Geomorphology (Subtotal =_�_)
Absent
Weak
Moderate
Strong
18 Continuity of channel bed and bank
0
1
2
3
2 Sinuosity of channel along thalweg
0 )
1
2
3
3 in- channel structure ex note -pool step -pool
n le- of sequence
0
1
2
3
4 Particle size of stream substrate
0
1
2
3
5 Active /relict floodplam
0
1
2
3
6 Depositional bars or benches
05
1
2
3
7 Recent alluvial deposits
0
1
2
3
8 Headcuts
15
1
2
3
9 Grade control
0
05
1
15
10 Natural valley
0
05
1
15
11 Second or greater order channel
o = 0
Yes = 3
artificial ditches are not rated see discussions in manual
R Hvdroloov (Subtotal= %L 1
12 Presence of Baseflow
0
1
2
3
13 Iron oxidizing bacteria
0
1
2
3
14 Leaf litter
15
1
05
0
15 Sediment on plants or debris
CO2
05
1
15
16 Organic debris lines or piles
0
05
1
15
17 Soil based evidence of high water table?
No = 0
Yes = 3
C Blolo Subtotal = S
18 Fibrous roots in streambed
3
2
1
0
19 Rooted upland plants in streambed
elly
2
1
0
20 Macrobenthos (note diversity and abundance)
0
1
2
3
21 Aquatic Mollusks
0
1
2
3
22 Fish
0
05
1
15
23 Crayfish
05
1
15
24 Amphibians
0
05
1
15
25 Algae
0
05
1
15
26 Wetland plants in streambed
FACW = 0 75 OBL = 15 etther = 0
perennial streams may also be identfed using other methods See p 35 of manual
Notes
Sketch
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-� fa ilt

NC DWQ Stream Identification Form Version 4 11 Al 3o+18, r,d e
Date g I ZZ It I
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Permit No
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
WATER QUALITY CLASSIFICATION REQUEST FORM
This form may be phoWopfed fbr use as an odpinal
PROJECT INFORMATION
in order to determine the receiving stream for a project in a coastal county or whether a State Stormwater
Management Permit will be required for a project in a non - coastal county the classification of the closest
downsiope surface waters (the surface waters that any sheet flow or overflow from the project would flow toward)
must be determined Please complete Sections 1 and II below DWO Staff will determine the receiving stream
classification, complete Section III and return the completed form to you
1 Project Name S R 19 412 Sed can ee ta" County Sang -re 1
2. Contact Person 54 o1nQw g)1 Mail+; $
3 Mailing Address SS-01 l3^--6ad a,r $1vd
4 City _W14 A4% m-t State��Zip 2942 Phone No q!o-341-Ye36
5 Name of closest dowrnsiope surface waters to T 4o S-w 'Runt G• C sw
6 Signature of contact person Date I t I
7 Is a imentation Erosion Control P or a CAMA Major Permit required? 93�ES ONO
II REQUIRED ITEMS
An 8 5" x 11" copy of the appropriate portion of a USGS quad sheet showing the projects property
boundaries receiving stream major roads or State Roads numbers and nearest town or city must be
attached
Mail the entire package to NCDENR Division of Water Duality
Surface Water Protection Section — Stormwater
at the Appropriate Contact Address (see the following page)
111 CLASSIFICATION REQUEST (To be completed by Regional Olf be personnel)
� ob
1 Name of surface waters / TD S
2 River Basin Index No
3 Classification (A established by the EMC) S
4 Proposed Classification, d applicable
5 State Stormwater Management Permit require YES fok
6 Signature of Regional Office pemonn Date I2 z3
cc DWO Regional Office
Consultant
Building Inspector
Central Files

Project Tracking No (Internal Use)
i
11 -04 -0017
NO SURVEY REQUIRED FORM
PROJECT INFORMATION
Project No SR 1940 [Balance Road] County Sampson
WBSNo 3C 082051 Document
FA No Funding ® State ❑ Federal
Federal (USACE) Permit Required? ❑ Yes ® No Permit Type NWP 14 and DWQ Certificate
Project Description Project will grade drain base and pave SR 1940 [Balance Road] All work will be
within the existing NCDOT 50 foot Right of Way [ROW]
SUMMARY OF CULTURAL RESOURCES REVIEW
Brief description of review activities results of review and conclusions
Review of HPO quad maps, historic designations roster and indexes was undertaken on April 21 2011
Based on this review there are no existing NR SL LD DE or SS properties in the Area of Potential
Effects No properties appear to be present in the project APE
Brief Explanation of why the available information provides a reliable basis for reasonably predicting
that there are no unidentified historic properties in the APE
The propose project will not extend beyond the existing ROW The absence of any recorded cultural
resources in the project vicinity precludes any impact to new location or cultural resources No further
work is warranted
SUPPORT DOCUMENTATION
See attached Map(s)
FINDING BY NCDOT CULTURAL RESOURCES PROFESSIONAL NO SURVEY REQUIRED
ARCHAEOLOGY
NCDOT
HISTORIC ARCHITECTURE (CIRCLE ONE)
Specialist
No Survey Reqi tred form for Minor Transportation Projects as Qualified to the 1007 Programmatic Agreement
NCDOTArchacotogy & Historic Archit cture Groups
y
Date

NO st im, FN RFQUTlU7D rORtil
PROj11C I LLN1U1U\L%110N
110tt�t ho
0 pis srf 3C 082051
I 11a
C t14 ICd (1 S tC 11 Pt tlMf tiLquiotd'
r -ri rn L? I In r, ,1 ( c r
(HA)11 -04 -0017
(f) nntt Sampson
1)oc1( 1,t 111
Fun Its, t' X')1 ti'. I icit -11
NWP 14 and DWQ
X Yt� No P,1rx1t Tf1, Certification
flip tact D(sc ( 11711 Grade, drain, baser grade, pave and widen SR 1940 (13allance
Road), plus three pipe replacements and one pipe addition Work confined to
existing ROW
%)TIV sl-s.t Y Of C UL I U AL R1 .()tjR€ r-t RFVII -\i
tir q & �c-11P'1on of 1 t I wo tic tri 111c s 1 c vtrfrc of I t t h 1 11111 ( 01011) c,1, % HPO quad maps historic
designations roster anJ mclexes and HPO'Veb rc%tevved on 10 May 2011 and ,gelded no 14P Sl LD LSE
or SS properties in the Area of Dotential Effects (APE) Sampson County cut tent CrS r1apping, aerial
Driogograpnyr and tax information indicated predominantly euitlVatL:J fields and c-evaral post 1 060
resource in the APE (v t_'VL -J 10 May 2-011) the Sampson County archttecturdl survey and rtldtLd
publication (T,,n But re, A 1 rnVe'0'0r1 of 4f - 0rC Are _'L-J e S�'Y n-.n If ^fvf 'uof 1 Ca a a Orl.--i Cry or C inton
r1181) rccorded no properties of concern in the APE Coogle rlapc Street View confirmed abst ncc of
critical histo rc strticturesJlmtndscapes it) the APE (vie ,t_d 12 May 20 t 1) As rhP protect r crate funded
G5 121 12(a) apnl es In addition its permIL areas are subject also to Section 10r revie d
No architectural survey is required for the project as currently defined
brat Fxplrn 11 an vftlhf tllc curt ft(hf gfibl n it s a 1'1 6101'. ota r fo rt(rsont his p1 tff,Clo'g
1,1at t1 1c a e rr) till, '01111 /1' d 111w;rt( pr 11i r to i 111 tat Wit, , APE extends 100 feet he} and lithe end of
proposed 3270 51 foot length of project and 100 feet to either side of center line to encompass dll
proposed construction accl.trties County GI51tax materials anJ other rlsuals support the absence of
st(In ant drehgtcCtural resources No National Register listed or — eligible propchues arc located tivtzhgn
the PPE
Should the design, funding, or permit requirements of the project change, please notify
NCDOT Historic Architecture as additional review may be necessary
SUPPORT D € }C'Ulll N I ♦1 tON
sup, it 1`itccl location map
PINDIV 13Y NC'D0T C 111 TITR 11 Rl, �(_)URC U S P ROf 1 ti51 €3N tit
NO SURb EY REQUIRED — Historic Structures
N( IN) l ( 11 tug 11 Rt,Oultc , '�l7_c 1 t11ti1
1 t r ,+ t ! h f r A
r 1 { r

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