20150571 Ver 1_Application_20150610 (2)

o�oF wnrF9oc
�
> �
O T
O�ce Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.0 November 2008
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
1 b. Specify Nationwide Permit (NWP) number: 14 or General Permit (GP) number:
1 c. Has the NWP or GP number been verifed by the Corps? ❑ Yes
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 For the record only for DWQ 401
because written approval is not required? Certification:
❑ 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.
/� .
For the record anly for Corps Permit:
❑ Yes � No
❑ Yes
1 g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h I❑ Yes
below.
1 h. Is the project located within a NC DCM Area of Environmental Concem (AEC)? I❑ Yes
2. Project Information
2a. Name of project: Hwy 401 safety upgrade
2b. County: Hoke
2c. Nearest municipality / town: Rock Fish
2d. Subdivision name: NIA
2e. NCDOT only, T.I.P. or state W_5208J
project no:
3. Owner Information
3a. Name on Recorded Deed: NC DOT
3b. Deed Book and Page No. NA
3c. Responsible Party (for LLC if
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: @ncdot.gov
►� .
/1 .
// .
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 Environmental Officer
4b. Name: Art King
4c. Business name North Carolina De artment of Trans ortation
!if annlir.ahlel� p P
4d. Street address: I 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: [e-mail]
5. Agent/Consultant Information (if applicable)
5a. Name:
Sb. Business name North Carolina De artment of Trans ortation
!if annlicahlol� P p
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:
Page 2 of 11
PCN Form — November 2008 Version

B. Project Information and Prior Project History
1. Property Identification
1 a. Property identification no. (tax PIN or parcel ID):
1b. Site coordinates (in decimal degrees);
1c. Propertysize:
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
proposed project:
2b. Water Quality Classification of nearest receiving water:
2c. River basin:
DB 971 PG 973
35.03231'N - 79.089086'W
1 acres
UT of Stewarts Creek
C
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:
Commercial/Church property
3b. List the total estimated acreage of all existing wetlands on the property:
Approx. 1 ac
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
0
3d. Explain the purpose of the proposed project:
To install an upgraded turn lane and turn about extension (bump out) between the Raeford Christian Fellowship Church
entrance and a neighboring housing development entrance, to improve safety along Hwy 401 for cars making a U- turn to
reach the church. Also to reduce traffic of larger truck attempting to make a left turn onto Wayside Drive from Hwy 401
east
3e. Describe the overall project in detail, including the type of equipment to be used:
To clear,grade, base the area for the bump out and build a fill section large to accommodate the bump out. Equip used:
dump trucks, track hoe, dozer, compactor, paving equipment.
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?
4b. If the Corps made the jurisdictional determination, what type
of determination was made?
� Yes ❑ No ❑ Unknown
❑ Preliminary ❑ Final
4c. If yes, who delineated the jurisdictional areas? Agency/Consultant Company:
Name (if known): Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5. Project
Sa. Have permits or certifications been requested or obtained for � Yes
this project (including all prior phases) in the past?
5b. If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
6a. Is this a phased project?
6b. If yes, explain.
❑ Yes
/� .
/� .
❑ Unknown
Page 3 of 11
PCN Form — Version 1.0 November 2008 Version

C. Proposed Impacts Inventory
1. Impacts Summary
1 a. 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 ofjurisdiction
number — Type of Type of wetland Forested (Corps - 404, Area of impact (acres)
Permanent (P) or impact (if known) DWQ — non-404, other)
Tem ora T
W1 � P❑ T Road Fill � Yes ❑ No � Corps 0.10 ac
� DWQ
W2 ❑ P❑ T ❑ Yes ❑ No � Corps
❑ DWQ
W3 ❑ P 0 T ❑ Yes ❑ No � Corps
❑ DWQ
W4 ❑ P❑ T ❑ Yes ❑ No � Corps
❑ DWQ
WS ❑ P❑ T ❑ Yes ❑ No � Carps
❑ DWQ
W6 ❑ P❑ T ❑ Yes ❑ No � Corps
❑ DWQ
2g. Total wetland impacts 0.10 ac
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 ❑PER ❑INT
S2 ❑ P❑ T ❑ PER ❑ INT
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
3h. Comments:
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 individuall 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)
Tem ora T
01 ❑P�T NA
02 ❑P❑T
03 ❑P❑T
04 ❑P�T
4f. Total open water impacts p
4g. Camments:
Page 5 of 11
PCN Form — November 2008 Versian

C. Proposed Impacts Inventory, continued
5. Pond or Lake Construction
If ond or lake construction ro osed, then com lete the chart below.
5a. 5b. Sc. Sd. 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
P1 NA
P2
Sf. Total
5g. Comments:
5h. Is a dam high hazard permit required?
❑ Yes � No If yes, permit ID no:
Si. Expected pond surtace 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 an im acts re uire miti ation, then ou 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 (square Zone 2 impact
Permanent (P) for impact Stream name mitigation feet) (square feet)
or Temporary required?
T
B1 ❑P❑T NA ❑Yes ❑No
BZ �P�T ❑Yes ❑No
B3 ❑ P❑ T ❑ Yes ❑ No
6h. Total buffer impacts
6i. Comments: Not in a buffer area.
Page 6 of 11
PCN Form — November 2008 Version

D. Impact Justification and Mitigation
Minimization
1 a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
Only the minimum amount of fill materal installed to provide a safe structure and meet current standards.
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?
2b. If yes, mitigation is required by (check all that apply):
2c. If yes, which mitigation option will be used for this
project?
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter)
3c. Comments:
4. Complete if Making a Payment to In-lieu Fee Program
4a. Approval letterfrom in-lieu fee program is attached.
4b. Stream mitigation requested:
4c. If using stream mitigation, stream temperature:
4d. Buffer mitigation requested (DWQ only):
4e. Riparian wetland mitigation requested:
4f. Non-riparian wetland mitigation requested:
4g. Coastal (tidal) wetland mitigation requested:
4h.. Comments:
❑ Yes � No
❑ DWQ ❑ Corps
❑ Mitigation bank
❑ Payment to in-lieu fee program
❑ Permittee Responsible Mitigation
Type
5. Complete if Using a Permittee Responsible Mitigation Plan
Quantity
❑ Yes
linear feet
warm, cool, cold
square feet
acres
acres
acres
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 ❑ 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.
Zone Reason for impact Total impact Multiplier Required mitigation
(square feet) (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

E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers identified
within one of the NC Riparian Buffer Protection Rules?
� b. If yes, then is a diffuse flow plan included?
2. Determination if
a
2a. Does the project require a Non-404 Jurisdictional General Permit?
2b. Is the project subject to General Certification 3704 or 3705?
of
❑ Yes � No
I ❑ Yes ❑ No
Plan
❑ Yes � No
3a. Is this project subject to any of the following state-implemented stormwater
management programs (check all that apply)?
If so, attach one copy of the approval letter from the DWQ and one copy of the
approved stormwater management plan.
3b. In which local government'sjurisdiction is this project?
3c. Is this local government certified to implement a state stormwater program?
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).
for DWQ 401 Unit Stormwater Review
4a. What is the overall
current site
❑ Yes � No
❑ Coastal counties
❑ HQW
❑ ORW
❑ Session Law 2006-246
❑ Other:
Hoke County
❑ Yes � No
4b. Does this project contain any areas that meet the criteria for "high density" per I� Yes
General Certifications 3704 and 3705? � No
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.
4d. Has a completed BMP Supplement Form with all required items been submitted � No
for each stormwater BMP? ❑ Yes
Page 9 of 11
PCN Form — Version 1.0 November 2008 Version

F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1 a. Does the project involve an expenditure of public (federal/state/local) funds or the � Yes
use of public (federal/state) land? � No
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)?
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
letter.) ❑ Yes ❑ No
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): Due to a
miscommunication, our directions to limit the clearing on the site to " hand clearing only, and no grubbing past the existing
toe of slope", was misintrepreted by the contractor to mean "to the toe of the newly proposed slope". This led to the
contractor clearing and grubbing within the suspected wetland area prior to receipt of the permit.
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.
NA
Page 10 of 11
PCN Form — Version 1.0 November 2008 Version

F. Supplementary Information, continued
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
Sa. Will this project occur in or near an area with federally protected species or � yes
habitat? � No
5b. Have you checked with the USFWS concerning Endangered Species Act
impacts? ❑ Yes � No
❑ Raleigh
Sc. If yes, indicate the USFWS Field Office you have contacted.
❑ Asheville
Sd. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
On site survey by NCDOT staff,and NCDOT SDV reference layer.
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?
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?
8. Flood 2one 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:
Sc. What source(s) did you use to make the floodplain determination? FEMA mapping
%��T G' • ,�' n�
C':� � 8-� is
Applicant/AgenYs Printed Name ApplicanUAgenYs Sign ture
(AgenPs signature is valid only if an authoiiz� letter from the applicant Date
is provided.
Page 11 of 11
PCN Form — November 2008 Versian