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• 1q�DSNR �VATE4QUAllTy Form Version 1 3 Dec 10 2008
AtJD STORMWATR 8RONcN
Pre-Construction Notification (PCN) Form
A Applicant Information
1 Processing
la Type(s)of approval sought from the
Corps non reporting ® Section 404 Permit ❑ Section 10 Permit
1 b Specify Nationwide Permit(NWP) number NWP 3 a4 4 ,4/W/7 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
le Is this notification solely for the record For the record only for DWQ 401 For the record only for Corps Permit
because written approval is not required? Certification
®Yew ❑ No ®Yes ❑ No
1f Is payment into a mitigation bank or in lieu fee program proposed for mitigation ❑Yes ® No
of impacts? If so attach the acceptance letter from mitigation bank or in lieu
fee program
1g Is the project located in any of NC s twenty coastal counties If yes answer 1h ❑ Yes ® No
below
1 h Is the project located within a NC DCM Area of Environmental Concern(AEC)? ❑ Yes ® No
2 Project Information
2a Name of project Proposed pipe replacement SR 1521 (Huntsboro Rd)
2b County Granville
2c Nearest municipality/town Oxford
2d Subdivision name N/A
2e NCDOT only T I P or state
project no
3 Owner Information
3a Name(s)on Recorded Deed NCDOT Division 5
3b Deed Book and Page No N/A
3c Responsible Party(for LLC if N/A
applicable)
3d Street address 2612 N Duke Street
3e City state zip Durham NC 27704
3f Telephone no [phone]
3g Fax no [phone]
3h Email address wbowman(a)ncdot goy
4 Applicant Information (if different from owner) N/A
5 Agent/Consultant Information(if applicable) N/A
Page 1 of 8
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) N/A
1 b Coordinates(in decimal degrees)
Site Latitude 36 3704 Longitude 78 52835
(DD DDDDDD) (DD DDDDDD)
lc Property size <0 01 acres
2 Surface Waters
2a Name of nearest body of water(stream river etc)to Flat Creek
proposed project
2b Water Quality Classification of nearest receiving water B
2c River basin Roanoke
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 existing pipes are old and separated and need to be replaced Site is surrounded by agricultural land
3b List the total estimated acreage of all existing wetlands on the property
NONE
3c List the total estimated linear feet of all existing streams(intermittent and perennial)on the property
52ft
3d Explain the purpose of the proposed project The pipe replacement will strengthen the roadway and shoulder sections
through this crossing
3e Describe the overall project in detail including the type of equipment to be used
The existing 2 @24 RCP with headwall that are 48ft long will be replaced with 2 @42 RCP with headwall that are 60ft
long Rip rap will be installed underlined with geotextile for long term stability surrounding the new pipes ends
Equipment may include a backhoe an excavator and grader
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?
0 ® No Unknown
Comments N/A
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 N/A
Name Of known) N/A Other N/A
4d If yes list the dates of the Corps jurisdictional determinations or State determinations and attach documentation
N/A
5 Project History
5a Have permits or certifications been requested or obtained for
11 Yes El No ❑ Unknown
this project(including all prior phases) in the past?
5b If yes explain in detail according to help file instructions
N/A
Page 2 of 8
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
N/A
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 N/A N/A ❑Yes Corps N/A
❑ No ❑ DWQ
2g Total Wetland Impacts NONE
2h Comments N/A
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)
Site 1 ® P ❑T fill Flat Creek ® PER ® Corps 3 12
Stream 1 ❑ INT ® DWQ
Site 1 ® P ❑T rip rap Flat Creek ® PER ® Corps 3 40
Stream 1 ❑ INT ® DWQ
Site 1 ❑ P ®T ® PER ® Corps 52
Stream 1 dewatenng Flat Creek 3
❑ INT ® DWQ concurrent
3h Total stream and tributary impacts 52
3i Comments rip rap will be placed on banks only for stabilization not within the flow line
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(P)or Of applicable)
Temporary(T)
01 ❑ P❑T N/A N/A N/A N/A
4f Total open water impacts NONE
4g Comments N/A
Page 3 of 8
PCN Form—Version 1 3 December 10 2008 Version

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 of (acres)
number pond
Flooded Filled Excavated Flooded Filled Excavated Flooded
P1 N/A N/A N/A N/A N/A N/A N/A N/A
P2
5f Total NONE NONE NONE NONE NONE NONE NONE
5g Comments N/A
5h Is a dam high hazard permit required?
❑Yes ® No If yes permit ID no N/A
5i Expected pond surface area(acres) N/A
5j Size of pond watershed (acres) N/A
5k Method of construction N/A
6 Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer then complete the chart below If yes then individually list all buffer impacts
below If 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 El Randleman
6b 6c 6d 6e 6f 6g
Buffer impact
number— Reason for Buffer Zone 1 impact Zone 2 impact
Permanent(P)or impact Stream name mitigation (square feet) (square feet)
Temporary(T) required?
Site ❑ P ❑T ❑Yes NONE NONE
Buffer Impact 1 ❑ No
6h Total buffer impacts NONE NONE
6i Comments N/A
D Impact Justification and Mitigation
1 Avoidance and Minimization
1 a Specifically describe measures taken to avoid or minimize the proposed impacts in designing project
These pipes will be replaced in the same alignment with pipes 12ft longer Rip rap armoring around the pipe ends/headwall
and tie in points to existing banks will be limited only to the amount necessary to ensure long term stability
lb Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques
Sediment and erosion control Best Management Practices for protection of surface waters will be enforced during project
construction
Page 4 of 8
PCN Form—Version 1 3 December 10 2008 Version

2 Compensatory Mitigation for Impacts to Waters of the U S or Waters of the State
2a Does the project require Compensatory Mitigation for ❑Yes ® No
impacts to Waters of the U S or Waters of the State?
2b If yes mitigation is required by(check all that apply) Cl DWQ ❑ Corps
❑ Mitigation bank
2c If yes which mitigation option will be used for this protect? ❑ Payment to in lieu fee program
❑ Permittee Responsible Mitigation
3 Complete if Using a Mitigation Bank
3a Name of Mitigation Bank N/A
3b Credits Purchased (attach receipt and letter) Type N/A Quantity N/A
3c Comments N/A
4 Complete if Making a Payment to In lieu Fee Program
4a Approval letter from in lieu fee program is attached ❑ Yes
4b Stream mitigation requested N/A linear feet
4c If using stream mitigation stream temperature ❑warm ❑ cool ['cold
4d Buffer mitigation requested (DWQ only) N/A square feet
4e Riparian wetland mitigation requested N/A acres
4f Non riparian wetland mitigation requested N/A acres
4g Coastal (tidal)wetland mitigation requested N/A acres
4h Comments N/A
5 Complete if Using a Permittee Responsible Mitigation Plan
5a If using a permittee responsible mitigation plan provide a description of the proposed mitigation plan
N/A
6 Buffer Mitigation (State Regulated Riparian Buffer Rules)—required by DWQ
6a Will the project result in an impact within a protected riparian buffer that requires ❑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 N/A N/A 3(2 for Catawba) N/A
Zone 2 N/A N/A 1 5 N/A
6f Total buffer mitigation required NONE
6g If buffer mitigation is required discuss what type of mitigation is proposed(e g payment to private mitigation bank
permittee responsible riparian buffer restoration payment into an approved in lieu fee fund) N/A
6h Comments N/A
Page 5 of 8
PCN Form—Version 1 3 December 10 2008 Version

E Stormwater Management and Diffuse Flow Plan (required by DWQ)
1 Diffuse Flow Plan
1 a Does the project include or is it adjacent to protected riparian buffers identified ❑Yes [E] No
within one of the NC Riparian Buffer Protection Rules?
1 b If yes then is a diffuse flow plan included? If no explain why
❑Yes No
Comments this pipe replacement will not alter storm water runoff at this site
2 Stormwater Management Plan
2a What is the overall percent imperviousness of this project? <20%
2b Does this project require a Stormwater Management Plan? ❑Yes ® No
2c If this project DOES NOT require a Stormwater Management Plan explain why
2d If this project DOES require a Stormwater Management Plan then provide a brief narrative description of the plan N/A
❑ Certified Local Government
2e Who will be responsible for the review of the Stormwater Management Plan? ❑ DWQ Stormwater Program
❑ DWQ 401 Unit
3 Certified Local Government Stormwater Review
3a In which local government s jurisdiction is this project?
❑ Phase II
3b Which of the following locally implemented stormwater management programs ❑ NSW
USMP
apply(check all that apply) ❑
❑Water Supply Watershed
❑ Other
3c Has the approved Stormwater Management Plan with proof of approval been ❑Yes ❑ No
attached? N/A
4 DWQ Stormwater Program Review
❑ Coastal counties
❑ HQW
4a Which of the following state implemented stormwater management programs apply ❑ ORW
(check all that apply) N/A ❑ Session Law 2006 246
❑ Other
4b Has the approved Stormwater Management Plan with proof of approval been
attached? N/A ❑Yes ❑ No
5 DWQ 401 Unit Stormwater Review
5a Does the Stormwater Management Plan meet the appropriate requirements? N/A ❑Yes ❑ No
5b Have all of the 401 Unit submittal requirements been met? N/A ❑Yes ❑ No
Page 6 of 8
PCN Form —Version 1 3 December 10 2008 Version

F Supplementary Information
1 Environmental Documentation (DWQ Requirement)
la Does the project involve an expenditure of public(federal/state/local)funds or the ®Yes ❑ No
use of public(federal/state) land?
1 b If you answered yes to the above does the project require preparation of an
environmental document pursuant to the requirements of the National or State ❑ Yes ® No
(North Carolina) Environmental Policy Act(NEPA/SEPA)?
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
letter) ❑ Yes ❑ No
Comments N/A
2 Violations (DWQ Requirement)
2a Is the site in violation of DWQ Wetland Rules (15A NCAC 2H 0500) Isolated
Wetland Rules(15A NCAC 2H 1300) DWQ Surface Water or Wetland Standards ❑Yes ® No
or Riparian Buffer Rules(15A NCAC 2B 0200)?
2b Is this an after the fact permit application? ❑Yes ® No
2c If you answered yes to one or both of the above questions provide an explanation of the violation(s) N/A
3 Cumulative Impacts(DWQ Requirement)
3a Will this project(based on past and reasonably anticipated future impacts) result in ❑Yes ® No
additional development which could impact nearby downstream water quality?
3b If you answered yes to the above submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy If you answered no provide a short narrative description
N/A
4 Sewage Disposal (DWQ Requirement)
4a Clearly detail the ultimate treatment methods and disposition (non discharge or discharge)of wastewater generated from
the proposed project or available capacity of the subject facility
N/A
Page 7 of 8
PCN Form—Version 1 3 December 10 2008 Version

5 Endangered Species and Designated Critical Habitat(Corps Requirement)
5a Will this project occur in or near an area with federally protected species or ❑Yes 0 N
habitat?
5b Have you checked with the USFWS concerning Endangered Species Act ❑Yes 0 N
impacts?
❑ Raleigh
5c If yes indicate the USFWS Field Office you have contacted
❑ Asheville
5d What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
http//www fws qov/nc es/es/countvfr html and NC Natural Heritage Program Database Element Occurrences
6 Essential Fish Habitat(Corps Requirement)
6a Will this project occur in or near an area designated as essential fish ❑Yes ® No
habitat?
6b What data sources did you use to determine whether your site would impact Essential Fish Habitat?
http//ocean flondamanne orq/efh coral/ims/viewer htm
7 Historic or Prehistoric Cultural Resources (Corps Requirement)
7a Will this project occur in or near an area that the state federal or tribal
governments have designated as having historic or cultural preservation ❑Yes 0 N
status(e g National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b What data sources did you use to determine whether your site would impact historic or archeological resources?
HPO s historic layer using GIS ArcView database http//qis ncdcr qov/hpoweb/
8 Flood Zone Designation (Corps Requirement)
8a Will this project occur in a FEMA designated 100 year floodplain? El Yes ® No
8b If yes explain how project meets FEMA requirements N/A
8c What source(s)did you use to make the floodplain determination? http//www ncfloodmaps com/
for J W Bowman P E rhs141 A/i, 17/(01.-411//-7e 10/09/12
Applicant/Agents Signatu
! Date
Applicant/Agent s Printed Name (Agents signature is valid only if an authorization let from the applicant
is provided 1
Page 8 of 8
PCN Form —Version 1 3 December 10 2008 Version

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Name OXFORD Location 036 3704 N 078 5283 W
Date 10/9/2012 Caption SR 1521 Huntsboro Road
Scale 1 inch equals 2000 feet Granville County
Pipe Replacement Site r la ore,
Copyright(C)1997 Maptech Inc J

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Maintenance- Pipe Replacement Site