20120447 Ver 1_Application_20120504

Office Use Only
Corps action ID no
DWQ project no
Form Version 1 3 Dec 10 2008
Page 1 of 11
PCN Form — Version 1 3 December 10 2008 Version
Pre- Constructio Notification (PCN) Form
A Appheant Information
1
Processing
la
Type(s) of approval sought from the
Corps
®Section 404 Permit El Section 10 Permit
1b
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
1h
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes
® No
2
Project Information
2a
Name of project
W 5504 Pitt 28 Bridge To Bridge Replacement SR 1711 Worthington Road Over Fork
Swamp
WBS Element Number 45476 1 1
2b
County
Pittt
2c
Nearest municipality / town
Wmterville
2d
Subdivision name
N/A
2e
NCDOT only T I P or state
project no
454761 1
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)
N/A
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
jbjohnson @ncdot gov
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
jbjohnson @ncdot gov
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)
W 5504 Pitt 28 SR 1711 Worthington Road Over Fork
Swamp
Latitude N 35 526854 Longitude W
1b Site coordinates (in decimal degrees)
77 369178
(DD DDDDDD) ( DD DDDDDD)
1c Property size
N/A acres
2 Surface Waters
2a Name of nearest body of water (stream river etc ) to
Fork Swamp Swift Creek a Tributary of The Neuse River
proposed project
2b Water Quality Classification of nearest receiving water
C Sw NSW
2c River basin
Neuse Middle Neuse 03020202
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 a paved Secondary State Highway Woodlands and Agriculture dominate the landscape
3b List the total estimated acreage of all existing wetlands on the property
4236 Square Feet (0 097 Acres) of 404 Wetland Impacts For The Bridge To Bridge Replacement
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
Bridge To Bridge Replacement the existing bridge has deteoriated and needs replacing
3e Describe the overall project in detail including the type of equipment to be used
The Existing 52 Long Timber Bridge on Timber Pilings Bridge will be replaced with a Proposed 70 Long 24 Cored Slab
Bridge The Utility Relocation will have No 404 Wetland Impacts nor Buffer Impacts Excavators Dump Trucks and Crane
Trucks will be used for the Bridge To Bridge Replacement
4 Jurisdictional Determinations
4a Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
El Yes ®No El Unknown
project (including all prior phases) in the past?
Comments
4b If the Corps made the jurisdictional determination what type
E:1 Preliminary El Final
of determination was made?
4c If yes who delineated the jurisdictional areas?
Agency /Consultant Company
Name (if known) Garcy Ward NCDWQ Jay
Other NCDWQ and NCDOT
Johnson NCDOT
4d If yes list the dates of the Corps jurisdictional determinations or State determinations and attach documentation
? ?? 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 1 3 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 T
W1 ® P ❑ T
Fill
Hardwood Bottom
® Yes
❑ No
® Corps
❑ DWQ
0 097 Acres
W2 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W3 ❑ P FIT
❑ Yes
❑ Corps
❑ No
❑ DWQ
W4 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W5 ❑ P ❑ T
❑ Yes
❑ Corps
❑ No
❑ DWQ
W6 ❑ P FIT
❑ Yes
❑ Corps
❑ No
❑ DWQ
2g Total wetland impacts
0 097 Acres
2h Comments 4236 Sq Ft (0 097 Acres) of 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
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
❑ PER
❑ Corps
❑ INT
❑ DWQ
S2 ❑ P ®T
Pilings in Stream
Fork Swamp
® PER
❑ INT
❑ Corps
❑ DWQ
20
38 Linear
Ft
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
38 Linear
Ft
31 Comments 38 Linear Ft 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
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
Tem ora T
01 ❑P ❑T
02 ❑P ❑T
03 ❑ PEI T
04 ❑P ❑T
4f Total open water impacts
None
4g Comments No Open Water Impacts
5 Pond or Lake Construction
If pond or lake construction proposed the 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
None
5g Comments None
5h Is a dam high hazard permit required
❑ Yes ❑ No If yes permit ID no
51 Expected pond surface area (acres)
51 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 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) or
for
Stream name
mitigation
(square feet)
(square feet)
Temporary T
impact
required?
B1 ®P ❑ T
Fill
Fork Swamp
® Nos
0 Sq Ft
2 Sq Ft
B2 ®P ❑ T
Fill
Fork Swamp
® Yes
os
1666 Sq Ft
1029 Sq Ft
B3 ®P ❑ T
Fill
Fork Swamp
® Nos
1222 Sq Ft
760 Sq Ft
6h Total buffer impacts
61 Comments See Page 6 A For Total Buffer Impacts
Page 6 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
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 T
01 ❑P ❑T
02 ❑P ❑T
03 ❑P ❑T
04 ❑P ❑T
4f Total open water impacts
None
4g Comments
5 Pond or Lake Construction
If pond or lake construction proposed the 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
None
5g Comments None
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 El Tar Pamlico El 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) or
for
Stream name
mitigation
(square feet)
(square feet)
Temporary T
impact
required
B1 ®P ❑ T
B 4 Fill
Fork Swamp
® Yes
os
1478 Sq Ft
936 Sq Ft
B2 ❑P ❑T
F-1 Yes
❑ No
B3 ❑P ❑T
El Yes
❑ No
6h Total buffer impacts
4366 Sq Ft
2727 Sq Ft
61 Comments 0 1 Acres of Buffer Zone 1 Impacts and 0 6 Acres of Buffer 2 Impacts
Page ,B' 0x10
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
There are 0 097 Acres of 404 Wetland Impacts for this Project and No Coastal Wetland Impacts However There are 4366
Square Feet of Buffer Zone 1 Impacts and 2727 Sq Ft of Buffer Zone 2 Impacts due to the installation of a Longer Bridge to
Replace the Existing Bridge The Utility Relocation will have No 404 wetland Impacts nor Buffer Impacts The Wetland Impacts
have been minimized to the greatest extent feasible
1 b 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
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
projects
❑ 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
❑ Yes ® No
buffer mitigation?
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
6c
6d
6e
Zone
Reason for impact
Total impact
Multiplier
Required mitigation
(square feet)
(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
permittee 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
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?
lb
If yes then is a diffuse flow plan included? If no explain why
Comments Stormwater will diffuse flow through vegetated wetlands before entering
stream There are No Weep Holes on the Proposed Bridge and stormwater is
treated at outlet pipe at Station 14 +62 with Rock Inlet Sediment Trap Type C
® Yes ❑ No
Stormwater will diffuse flow through vegetated uplands before entering stream
Stormwater is treated at outlet pipe at Station 16 +71 with Rock Inlet Sediment Trap
Type C Stormwater will filter and diffuse flow through Special Sediment Control
Fence
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?
® 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
Stormwater will diffuse flow through vegetated wetlands before entering stream There are No Weep Holes on`the
Proposed Bridge and stormwater is treated at outlet pipe at Station 14 +62 with Rock
Inlet Sediment Trap Type C
Stormwater will diffuse flow through vegetated uplands before entering stream Stormwater is treated at outlet pipe at
Station 16 +71 with Rock Inlet Sediment Trap Type C Stormwater will filter and diffuse flow through Special Sediment
Control Fence
❑ 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 governments jurisdiction is this project?
N/A
❑ Phase II
3b
Which of the following locally implemented stormwater management programs
❑ 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 ® 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 NPDES Permit
4b
Has the approved Stormwater Management Plan with proof of approval been
attached?
❑ Yes ® No
Page 9 of 11
PCN Form — Version 1 3 December 10 2008 Version

5
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
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 ❑ 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

5 Endangered Species and Designated Critical Habitat (Corps Requirement)
5a Will this protect occur in or near an area with federally protected species or -F1 Yes
habitat? I
5b Have you checked with the USFWS concerning Endangered Species Act ❑ Yes
impacts?
5c if yes ind icate the USFWS Field Office you have contacted
❑ Raleigh
❑ Asheville
® No
® No
5d What data sources did you use to determine whether your site would Impact Endangered Species or Designated Critical
Habitat?
Mr Travis Wilson NCWRC Mr Mike Sanderson NCDOT NEU
6 Essential Fish Habitat (Corps Requirement)
6a Will this protect occur in or near an area designated as essential fish habitat? T ❑ Yes ® No
6b What data sources did you use to determine whether your site would impact Essential Fish Habitat?
Mr Travis Wilson NCWRC
7 Historic or Prehistoric Cultural Resources (Corps Requirement)
7a Will this protect 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 HEU Historic Architecture and Archaeology
8 Flood Zone Designation (Corps Requirement)
8a Will this protect occur in a FEMA designated 100 year floodplain? ( ® Yes ❑ No
8b If yes explain how protect meets FEMA requirements Bridge designed to no rise standards
8c What source(s) did you use to make the floodplain determination? FEMA FIRM Maps
Jay B lohnson
Applicant/Agent s Printed Name p I can gents Signature
(Agents signatu is v onl d an authorization letter from the applicant
is provided)
Apnl12 2012
Date
Page 11 of 11
PCN Form - Version 1 3 December 10 2008 Version

PITT 28
SR 1 711, WORTHINGTON ROAD
OVER FORK SWAMP
REPLACE EXISTING 52'L ONG BY26' WIDE
TIMBER BRIDGE WITHA 55'x 33' CORED SLAB BRIDGE
[GREENVILLE,SE USGS QUAD MAP F.A. NUMBER HSIP- 1711(5)
HEFT NUMBER 56 -B OF THE FORK SWAMP C;Sw; NSW
OIL SURVEY OF PITT COUNTY WBS ELEMENT NUMBER 45476.1.1
JULY 279 2011 TIP NUMBER W -5504 FIRM PANEL 4685 J
MIDDLE NEUSE 03020202 MAP NUMBER 3720468500 J
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