20120413 Ver 1_Application_20120507

Moore SR 1825 DWQ Project # 120413 Page 1 of 1
Moore SR 1825 DWQ Project # 120413
Herndon, Mason
Sent Monday May 07 2012 3 32 PM
To Carrillo Sonia
Cc Smith Ronnie D SAW [Ronnie D Smith @usace army mil] King Art C
Importance High
Sonia Division 8 submitted an application for SR 1825 in Moore County (DWQ Project No 120413) The Army
Corps Of Engineers has reviewed the application and determined it can be authorized under NW 3 rather than
NW 14 as stated in the application After reviewing the revised application which was submitted tome
electronically from Division 8 the permanent impacts for this pipe replacement is 2�t rather than the 80 ft has
stated in the original application therefore this project would not require written authorization from DWQ
under NW 3 Would you please see if we can stopped the permit fee transaction and make the appropriate
changes in the BIMS database As soon as I get confirmation from the Corps that the project Is authorized
under NW 3 1 will send you a copy for your records If you need any additional information from me please do
not hesitate to contact me I apologize for the confusion and inconvenience
Thank you for all you dol
MH
Mason Herndon
Environmental Senior Specialist
NCDENR Division of Water Quality
Surface Water Protection
mason herndon @ncdenr gov
Phone [phone]
E mail correspondence to and from this address may be subject to the
North Carolina Public Records Law and may be disclosed to third parties
https / /mail nc gov /owa/ ?ae= Item &t =IPM Note &id= RgAAAADMSzLcd9W2TJH14 %2bm 5/10/2012

FW SR 1825 (UNCLASSIFIED) Page 1 of 2
FW SR 1825 (UNCLASSIFIED)
Herndon, Mason
Sent Monday May 07 2012 3 49 PM
To Carrillo Sonia
Attachments SR 1825 Moore PCN docSR1825 doc (471 KB)
Sonia attached is a revised PCN for SR 1825 in Moore County (DWQ Project #
120413) The permanent stream impacts were reduced from 80 ft to 25 ft The e-
mail chain below includes the discussion by the USACE that the project can be
authorized under NW 3 rather than NW 14 as stated in the application I will still
send you the copy of the NW 3 when it is issued by the Corps
Thank you''''
MH
Mason Herndon
Environmental Senior Specialist
NCDENR Division of Water Quality
Surface Water Protection
mason herndon @ncdenr gov
Phone [phone]
E -mail correspondence to and from this address may be subject to the
North Carolina Public Records Law and may be disclosed to third parties
- - - -- Original Message---- -
From King Art C
Sent Monday April 30 2012 5 02 PM
To Smith Ronnie D SAW
Cc Herndon Mason
Subject RE SR 1825 (UNCLASSIFIED)
Ronnie Mason
*Attached is a revised PCN with the corrected total of impacted stream channel
length
*There are no plans to widen the road travel lanes only minor widening at the pipe
location to achieve a stable shoulder slope *The riprap will be held above the
plane of ordinary high water
*I agree with your assessment of the use of NWP 43 for this project however in the
past both the Corp and DWQ had objected to the use of NWP #3 in this situation when
the newly installed length of pipe exceeds the existing pipe by more than a
specified number of feet
I will also be submitting via separate email a revised PCN by email to correct the
same mistake in pipe length for the project on SR -2162 Mark Teague Rd in Chatham
County
Mason will you forward the corrected pages to Ms Carrillo in Raleigh I don t
have her current email address
Thanks
Art
- - - -- Original Message---- -
From Smith Ronnie D SAW [mai.lto Ronnie D Smith @usace army mil]
Sent Monday April 30 2012 8 42 AM
To King Art C
Cc Herndon Mason
https Hma11 nc gov /owa/ ?ae= Item &t =IPM Note &1d= RgAAAADMSzLcd9W2TJHI4 %2bm 5/10/2012

FW SR 1825 (UNCLASSIFIED)
Subject SR 1825 (UNCLASSIFIED)
Classification UNCLASSIFIED
Caveats NONE
Page 2 of 2
On April 25 2012 I received your request to use nationwide permit 14 for 120
linear feet of stream impact for the replacement of a culvert Please provide the
following information
* The amount of stream channel already piped /impacted should not be included in the
impact table of the PCN Please provide a revised stream impact calculation
* How much will the road be widened? What are the dimensions of the proposed
roadway? How wide are the proposed lanes shoulders and fill slopes?
* Will the proposed rip -rap be placed below the OHWM? If so the impacts need to be
included in the PCN
* The PCN states that the purpose of the project is to replace a deficient and
misaligned pipe If this is not a secondary road widening project and the intent of
the project is to replace a single pipe at the given location then this project
should qualify for NWP 3
If you have any questions feel free to contact me
Ronnie Smith
Project Manager
U S Army Corps of Engineers
69 Darlington Avenue
Wilmington North Carolina 28403
Office 910 - 251 -4829
Fax [phone]
Website http / /www saw usace army mil /WETLANDS
The Wilmington District is committed to providing the highest level of support to
the public To help us ensure we continue to do so please complete the Customer
Satisfaction Survey located at our website at
http / /per2 nwp usace army mil /survey html to complete the survey online
E
Classification UNCLASSIFIED
Caveats NONE
Email correspondence to and from this sender is subject to the N C Public Records
Law and may be disclosed to third parties
https //mail nc gov /owa/ ?ae= Item &t =IPM Note &id= RgAAAADMSzLcd9W2TJH14 %2bm 5/10/2012

\o��F W ATF9OG
r
o -c
Office Use Only
Corps action ID no
DWQ project no
Form Version 1 0 November 2008
Page 1 of 11
PCN Form — Version 1 0 November 2008 Version
Pre - Construction Notification (PCN) Form
A
Applicant Information
1
Processing
1a
Type(s) of approval sought from the
Corps
® Section 404 Permit ❑Section 10 Permit
lb
Specify Nationwide Permit (NWP) number 14 or General Permit (GP) number
1c
Has the NWP or GP number been verified by the Corps?
❑ Yes
® No
1 d
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
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
SR 1825
2b
County
Moore
2c
Nearest municipality / town
Vass
2d
Subdivision name
N/A
2e
NCDOT only T I P or state
project no
8B 206311
3
Owner Information
3a
Name on Recorded Deed
NC DOT
3b
Deed Book and Page No
3c
Responsible Party (for LLC if
applicable)
3d
Street address
PO BOX 1067
3e
City state zip
Aberdeen NC 28315
3f
Telephone no
910 944 2344
3g
Fax no
910 944 5623
3h
Email address
rwhancock @ncdot gov
Page 1 of 11
PCN Form — Version 1 0 November 2008 Version

Section A Applicant Information continued
4
Applicant Information (if different from owner)
4a
Applicant is
❑ Agent ® Other specify Division Engineer
4b
Name
Richard W Hancock
4c
Business name
(if applicable)
North Carolina Department of Transportation
4d
Street address
PO BOX 1067
4e
City state zip
Aberdeen NC 28315
4f
Telephone no
910 944 2344
4g
Fax no
910 944 5623
4h
Email address
rwhancock @ncdot gov
5
Agent/Consultant Information (if applicable)
5a
Name
Dean R Garner
5b
Business name
(if applicable)
North Carolina Department of Transportation/ Bridge Maintenance
5c
Street address
1404C East Raleigh St PO Box 289
5d
City state zip
Siler City NC 27344
5e
Telephone no
919 742 5649
5f
Fax no
919 663 0214
5g
Email address
drgarner @ncdot gov
Page 2 of 11
PCN Form — November 2008 Version

B Project Information and Prior Project History
1 Property Identification
1a Property identification no (tax PIN or parcel ID)
SR 1825 over UT into Big Branch
lb Site coordinates (in decimal degrees)
35 2903 N 79 2685 W
1 c Property size
acres
2 Surface Waters
2a Name of nearest body of water (stream river etc ) to
proposed project
Big Branch
2b Water Quality Classification of nearest receiving water
WS III
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
Rural /Residential Area SR 1825 is a paved SecondaryState Highway
3b List the total estimated acreage of all existing wetlands on the property
0
3c List the total estimated linear feet of all existing streams (intermittent and perennial) on the property
120 ft
3d Explain the purpose of the proposed project
Replace deficient and mis aligned pipe with new pipe
3e Describe the overall project in detail including the type of equipment to be used
Remove existing pipe with excavator and replace with new pipe utilizing truck crane and excavator
4 Jurisdictional Determinations
4a Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past?
❑ Yes ® No ❑ Unknown
4b If the Corps made the jurisdictional determination what type
of determination was made?
❑ preliminary ❑ Final
4c If yes who delineated the jurisdictional areas?
Name (if known)
Agency /Consultant Company
Other
4d If yes list the dates of the Corps jurisdictional determinations or State determinations and attach documentation
5 Project History
5a Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past?
❑ Yes ® No ❑ Unknown
5b If yes explain in detail according to help file instructions
6 Future Project Plans
6a Is this a phased project?
❑ Yes ® No
6b If yes explain
Page 3 of 11
PCN Form — Version 1 0 November 2008 Version

C Proposed Impacts Inventory
1 Impacts Summary
1a 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
Type of wetland
Forested
(Corps 404
Area of impact (acres)
Permanent (P) or
impact
(if known)
DWQ — non 404 other)
Temporary T
W1 ❑ P ❑ T
NA
❑ Yes ❑ No
❑ Corps
❑ DWQ
W2 ❑ P ❑ T
❑ Yes ❑ No
❑ Corps
❑ DWQ
W3 ❑ P ❑ T
❑ Yes ❑ No
❑ Corps
❑ DWQ
W4 ❑ P ❑ T
❑ Yes ❑ No
❑ Corps
❑ DWQ
W5 ❑ P ❑ T
❑ Yes ❑ No
❑ Corps
❑ DWQ
W6 ❑ P ❑ T
❑ Yes ❑ No
❑ Corps
❑ 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
Stream impact
Type of
Stream name
Perennial (PER) or
Average stream width (feet)
Impact
number
impact
intermittent (INT)?
length
Permanent (P) or
(linear feet)
Temporary (T)
S1 ® P ❑ T
Pipe
UT of Big Branch
® PER ❑ INT
810
25 ft
S2 ❑ P ® T
Dewater
® PER ❑ INT
40ft
S3 ❑ P ❑ T
❑ PER ❑ INT
S4 ❑P
E:1 PER ®INT
S5 ❑ P ❑ T
❑ PER ❑ INT
S6 ❑P
PER ❑INT
3g Total stream and tributary impacts
65
3h Comments 25 ft of permanent impact for pipe and 40 ft of temporary impact for dewatenng
Page 4 of 11
PCN Form — Version 1 0 November 2008 Version

C Proposed Impacts Inventory continued
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
impact number
waterbody
Type of impact
Waterbody type
Area of impact (acres)
— Permanent
(if
(P) or
applicable)
Temporary T
01 ❑P ❑T
NA
02 ❑P ❑T
03 ❑P ❑T
04 ❑P ❑T
M Total open water impacts
0
4g Comments
Page 5 of 11
PCN Form — November 2008 Version

C Proposed Impacts Inventory continued
5 Pond or Lake Construction
If pond or lake construction pro osed then complete the chart below
5a
5b
5c
5d
5e
Wetland Impacts (acres)
Stream Impacts (feet)
Upland
Pond ID
Proposed use or
(acres)
number
purpose of pond
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
Pi
NA
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 y ou MUST fill out Section D of this form
6a
❑ Neuse El Tar Pamlico F] Other
Project is in which protected basin?
❑ Catawba ❑ Randleman
6b
6c
6d
6e
6f
6g
Buffer impact
number —
Reason
Buffer
Zone 1 impact (square
Zone 2 impact
Permanent (P)
for impact
Stream name
mitigation
feet)
(square feet)
or Temporary
required?
T
B1 ❑P ❑T
NA
El Yes ❑No
B2 ❑P ❑T
El Yes ❑No
B3 ❑P ❑T
El Yes El No
6h Total buffer impacts
61 Comments Not in a buffer area
Page 6 of 11
PCN Form — November 2008 Version

t
D Impact Justification and Mitigation
1 Avoidance and Minimization
1a Specifically describe measures taken to avoid or minimize the proposed impacts in designing project
Install temporary steel sheet piles and divert stream by pumping water around work area
1 b Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques
Install erosion control devices and compliance with all current BMP
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
El 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 0 November 2008 Version

D Impact Justification and Mitigation continued
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
Reason for impact
Total impact
(square feet)
Multiplier
Required mitigation
(square feet)
Zone 1
NA
3 (2 for Catawba)
Zone 2
1 5
Total buffer mitigation required
6c 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)
6d Comments
Page 8 of 11
PCN Form — November 2008 Version

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Oa0� WAT�9�G
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Office Use Only
Corps action ID no
DWQ project no
Form Version 1 0 November 2008
Page 1 of 11
PCN Form — Version 1 0 November 2008 Version
Pre - Construction Notification (PCN) Form
A
Applicant Information
1
Processing
1a
Type(s) of approval sought from the
Corps
®Section 404 Permit El Section 10 Permit
1b Specify Nationwide Permit (NWP) number 14 or General Permit (GP) number
1c
Has the NWP or GP number been verified by the Corps?
❑ Yes
® No
1 d
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
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
SR 1825
2b
County
Moore
2c
Nearest municipality / town
Vass
2d
Subdivision name
N/A
2e
NCDOT only T I P or state
project no
8B 206311
3
Owner Information
3a
Name on Recorded Deed
NC DOT
3b
Deed Book and Page No
3c
Responsible Party (for LLC if
applicable)
3d
Street address
PO BOX 1067
3e
City state zip
Aberdeen NC 28315
3f
Telephone no
910 944 2344
3g
Fax no
910 944 5623
3h
Email address
rwhancock @ncdot gov
Page 1 of 11
PCN Form — Version 1 0 November 2008 Version

Section A Applicant Information continued
4
Applicant Information (if different from owner)
4a
Applicant is
❑ Agent ® Other specify Division Engineer
4b
Name
Richard W Hancock
4c
Business name
(if applicable)
North Carolina Department of Transportation
4d
Street address
PO BOX 1067
4e
City state zip
Aberdeen NC 28315
4f
Telephone no
910 944 2344
4g
Fax no
910 944 5623
4h
Email address
rwhancock @ncdot gov
5
Agent/Consultant Information (if applicable)
5a
Name
Dean R Garner
5b
Business name
(if applicable)
North Carolina Department of Transportation/ Bridge Maintenance
5c
Street address
1404C East Raleigh St PO Box 289
5d
City state zip
Siler City NC 27344
5e
Telephone no
919 742 5649
5f
Fax no
919 663 0214
5g
Email address
drgarner @ncdot gov
Page 2 of 11
PCN Form — November 2008 Version

B Project Information and Prior Project History
1 Property Identification
1a Property identification no (tax PIN or parcel ID)
SR 1825 over UT into Big Branch
1 b Site coordinates (in decimal degrees)
35 2903 N 79 2685 W
1 c Property size
acres
2 Surface Waters
2a Name of nearest body of water (stream river etc ) to
proposed project
Big Branch
2b Water Quality Classification of nearest receiving water
WS III
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
Rural /Residential Area SR 1825 is a paved SecondaryState Highway
3b List the total estimated acreage of all existing wetlands on the property
0
3c List the total estimated linear feet of all existing streams (intermittent and perennial) on the property
120 ft
3d Explain the purpose of the proposed project
Replace deficient and mis aligned pipe with new pipe
3e Describe the overall project in detail including the type of equipment to be used
Remove existing pipe with excavator and replace with new pipe utilizing truck crane and excavator
4 Jurisdictional Determinations
4a Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past?
❑ Yes ® No ❑ Unknown
4b If the Corps made the jurisdictional determination what type
of determination was made?
❑ Preliminary ❑ Final
4c If yes who delineated the jurisdictional areas?
Name (if known)
Agency /Consultant Company
Other
4d If yes list the dates of the Corps jurisdictional determinations or State determinations and attach documentation
5 Project History
5a Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past?
❑ Yes ® No ❑ Unknown
5b If yes explain in detail according to help file instructions
6 Future Project Plans
6a Is this a phased project?
❑ Yes ® No
6b If yes explain
Page 3 of 11
PCN Form — Version 1 0 November 2008 Version

C Proposed Impacts Inventory
1 Impacts Summary
1a 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
Type of wetland
Forested
(Corps 404
Area of impact (acres)
Permanent (P) or
impact
(if known)
DWQ - non 404 other)
Temporary T
W1 ❑ P ❑ T
NA
❑ Yes ❑ No
❑ Corps
❑ DWQ
W2 ❑ P ❑ T
❑ Yes ❑ No
❑ Corps
❑ DWQ
W3 ❑ P ❑ T
❑ Yes ❑ No
❑ Corps
❑ DWQ
W4 ❑ P ❑ T
❑ Yes ❑ No
❑ Corps
❑ DWQ
W5 ❑ P ❑ T
❑ Yes ❑ No
❑ Corps
❑ DWQ
W6 ❑ P ❑ T
❑ Yes ❑ No
❑ Corps
❑ 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
Stream impact
Type of
Stream name
Perennial (PER) or
Average stream width (feet)
Impact
number
impact
intermittent (INT)?
length
Permanent (P) or
(linear feet)
Temporary (T)
S1 ®P ❑ T
Pipe
UT of Big Branch
® PER ❑ INT
810
25 ft
S2-[-] P ® T
Dewater
® PER ❑ INT
40ft
S3 ❑ P ❑ T
❑ PER ❑ INT
S4 ❑ P ❑ T
❑ PER ® INT
S5 ❑ P ❑ T
❑ PER ❑ INT
S6 ❑ P ❑ T
❑ PER ❑ INT
3g Total stream and tributary impacts
65
3h Comments 25 ft of permanent impact for pipe and 40 ft of temporary impact for dewatering
Page 4 of 11
PCN Form - Version 1 0 November 2008 Version

C Proposed Impacts Inventory continued
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 o en water im acts below
4a
4b
4c
4d
4e
Open water
Name of
impact number
waterbody
Type of impact
Waterbody type
Area of impact (acres)
— Permanent
(if
(P) or
applicable)
Temporary T
01 ❑P ❑T
NA
02 ❑P ❑T
03 ❑P
04 ❑P
4f Total open water impacts
0
4g Comments
Page 5 of 11
PCN Form — November 2008 Version

C Proposed Impacts Inventory continued
5 Pond or Lake Construction
If pond or lake construction pro osed then complete the chart below
5a
5b
5c
5d
5e
Wetland Impacts (acres)
Stream Impacts (feet)
Upland
Pond ID
Proposed use or
(acres)
number
purpose of pond
Flooded
Filled
Excavated
Flooded
� Filled
Excavated
Flooded
Pi
NA
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 y ou MUST fill out Section D of this form
6a
❑ Neuse E] Tar Pamlico [:1 Other
Project is in which protected basin?
❑ Catawba ❑ Randleman
6b
6c
6d
6e
6f
6g
Buffer impact
number —
Reason
Buffer
Zone 1 impact (square
Zone 2 impact
Permanent (P)
for impact
Stream name
mitigation
feet)
(square feet)
or Temporary
required?
T
B1 ❑P ❑T
NA
❑Yes El No
B2 ❑ P ❑ T
❑ Yes ❑ No
B3 ❑ P ❑ T
❑ Yes ❑ No
6h Total buffer impacts
61 Comments Not in a buffer area
Page 6 of 11
PCN Form — November 2008 Version

D Impact Justification and Mitigation
1 Avoidance and Minimization
la Specifically describe measures taken to avoid or minimize the proposed impacts in designing project
Install temporary steel sheet piles and divert stream by pumping water around work area
1 b Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques
Install erosion control devices and compliance with all current BMP
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
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PCN Form — Version 1 0 November 2008 Version

D Impact Justification and Mitigation continued
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
Reason for impact
Total impact
(square feet)
Multiplier
Required mitigation
(square feet)
Zone 1
NA
3 (2 for Catawba)
Zone 2
1 5
Total buffer mitigation required
6c 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)
6d Comments
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PCN Form — November 2008 Version

E
Stormwater Management and Diffuse Flow Plan (required by DWQ)
1
Diffuse Flow Plan
la
Does the project include or is it adjacent to protected riparian buffers identified
❑ Yes
® No
within one of the NC Riparian Buffer Protection Rules?
lb
If yes then is a diffuse flow plan included?
❑ Yes
❑ No
2
Determination if the Project Requires a Stormwater Management Plan
2a
Does the project require a Non 404 Jurisdictional General Permit?
❑ Yes
® No
2b
Is the project subject to General Certification 3704 or 3705?
❑ Yes
❑ No
3
Determination of Stormwater Review Jurisdiction
3a
Is this project subject to any of the following state implemented stormwater
❑ Coastal counties
management programs (check all that apply)?
❑ HQW
❑ ORW
If so attach one copy of the approval letter from the DWQ and one copy of the
❑ Session
Law 2006 246
approved stormwater management plan
❑ Other
3b
In which local government s jurisdiction is this project?
3c
Is this local government certified to implement a state stormwater program?
❑ Yes
❑ No
If so attach one copy of the approval letter from the local government and one copy
of the approved stormwater management plan (or one copy of the approved
Stormwater management plan stamped as approved)
4
Information Required for DWQ 401 Unit Stormwater Review
4a
What is the overall percent imperviousness according to the most current site plan?
33%
4b
Does this project contain any areas that meet the criteria for high density per
❑ Yes
® No
General Certifications 3704 and 3705?
4c
If the site is over 24% impervious and /or contains high density areas then provide a brief narrative description of the
stormwater management plan
Stormwater management will be in complience with the current BMP manual for sediment and erosion controlls
4d
Has a completed BMP Supplement Form with all required items been submitted
❑ Yes
® No
for each stormwater BMP?
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PCN Form — Version 1 0 November 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)?
1 c
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
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PCN Form — Version 1 0 November 2008 Version

F Supplementary Information continued
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?
On site survey and Natural Heritage layer on NCDOT SDV program
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?
SDV
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?
SDV Natural heritage layer
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?
Applicant/Agents Printed Name
Applicant/Agents Signature
(Agents signature is valid only if an authorization letter from the applicant
Date
is provided
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PCN Form — November 2008 Version