20151251 Ver 1_Mitigation Information_20151222

U.S. ARMY CORPS OF ENGINEERS
Wilmington District
Compensatorv Miti�ation Responsibilitv Transfer Form
Permittee: NCDOT Action ID: SAW-2015-02553
Project Name: NCDOT / SR 2363 / Beal Road / Bridge146 / Rock Creek / Alamance County / Di►rision 7 County: Alamance
Instructions to Permittee: The Permittee must provide a copy of this form to the Mitigation Sponsor, either an approved
Mitigation Bank or the North Carolina Division of Mitigation Services (NCDMS), who will then sign the form to verify the
transfer of the mitigation responsibility. Once the Sponsor has signed this form, it is the Permittee's responsibility to ensure
that to the U.S. Army Corps of Engineers (USACE) Project Manager identified on page two is in receipt of a signed copy of this
form before conducting authorized impacts, unless otherwise specified below. If more than one mitigation Sponsor will be
used to provide the mitigation associated with the permit, or if the impacts and/or the mitigation will occur in more than one
8-digit Hydrologic Unit Code (HUC), multiple forms will be attached to the permit, and the separate forms for each Sponsor
and/or HUC must be provided to the appropriate mitigation Sponsors.
Instructions to Sponsor: The Sponsor must verify that the mitigation requirements (credits) shown below are available at the
identified site. By signing below, the Sponsor is accepting full responsibility for the identified mitigation, regardless of
whether or not they have received payment from the Permittee. Once the form is signed, the Sponsor must update the bank
ledger and provide a copy of the signed form and the updated bank ledger to the Permittee, the USACE Project Manager, and
the Wilmington District Mitigation Office (see contact information on page 2). The Sponsor must also comply with all
reporting requirements established in their authorizing instrument.
Permitted Impacts and Compensatory Mitigation Requirements:
Permitted Impacts Requiring Mitigation* 8-digit HUC and Basin: 03030002, Cape Fear River Basin
Stream Imaacts (linear
Warm � Cool � Cold
92
Wetland Impacts (
an Riverine Riparian Non-Riverine
Coastal
*If more than one mitigation sponsor will be used for the permit, only include impacts to be mitigated by this sponsor.
�pensatory Mitigation Requirements:
Stream Mitigation (credits)
Warm Cool Cold
92
HUC and Basin: 03030002, Cape Fear River Basin
Wetland Mitigation (credits)
rian Riverine Riparian Non-Riverine Non-Riparian Coastal
Mitigation Site Debited: NCDMS
(List the name of the bank to be debited. For umbrella banks, also list the specific site. For NCDMS, list NCDMS. If the NCDMS
acceptance letter identifies a specific site, also list the specific site to be debited).
Section to be completed by the Mitigation Sponsor
Statement of Mitigation Liability Acceptance: I, the undersigned, verify that I am authorized to approve mitigation
transactions for the Mitigation Sponsor shown below, and I certify that the 5ponsor agrees to accept full responsibility for
providing the mitigation identified in this document {see the table above), associated with the USACE Permittee and Action
ID number shown. I also verify that released credits (and/or advance credits for NCDMS), as approved by the USACE, are
currently available at the mitigation site identified above. Further, I understand that if the Sponsor fails to provide the
required compensatory mitigation, the USACE Wilmington District Engineer may pursue measures against the Sponsor to
ensure compliance associated with the mitigation requirements.
Mitigation Sponsor Nam
of Sponsor's Authorized Represe
re of Sponsor's Authorized Representative
of
Page 1 of 2 Form Updated 23 November, 2015

USACE Wilmington District
Compensatory Mitigation Responsibility Transfer Form, Page 2
Conditions for Transfer of Compensatory Mitigation Credit:
• Once this document has been signed by the Mitigation Sponsor and the USACE is in receipt of the signed form, the
Permittee is no longer responsible for providing the mitigation identified in this form, though the Permittee remains
responsible for any other mitigation requirements stated in the permit conditions.
• Construction within jurisdictional areas authorized by the permit identified on page one of this form can begin only after
the USACE is in receipt of a copy �f this document signed by the Sponsor, confirming that the Sponsor has accepted
responsibility for providing the mitigation requirements listed herein. For authorized impacts conducted by the North
Carolina Department of Transportation (NCDOT), construction within jurisdictional areas may proceed upon permit
issuance; however, a copy of this form signed by the 5ponsor must be provided to the USACE within 30 days of permit
issuance. NCDOT remains fully responsible for the mitigation until the USACE has received this form, confirming that the
Sponsor has accepted responsibility for providing the mitigation requirements listed herein.
• Signed copies of this document must be retained by the Permittee, Mitigation 5ponsor, and in the USACE administrative
records for both the permit and the Bank/ILF Instrument. It is the Permittee's responsibility to ensure that the USACE
Project Manager (address below) is provided with a signed copy of this form.
� If changes are proposed to the type, amount, or location of mitigation after this form has been signed and returned to
the USACE, the Sponsor must obtain case-by-case approval from the USACE Project Manager and/or North Carolina
Interagency Review Team (NCIRT). If approved, higher mitigation ratios may be applied, as per current District guidance
and a new version of this form must be completed and included in the USACE administrative records for both the permit
and the Bank/ILF Instrument.
Comments/Additional Conditions:
This form is not valid unless signed below by the USACE Project Manager and by the Mitigation Sponsor on Page 1. Once
signed, the Sponsorshould provide copies of this form olong with an updated bank ledger to: 3J the Permittee, 2) the USACE
Projett Manager at the address 6elow, and 3) the Wilmington District Mitigation Office, Attn: Todd TugweN, 11405 falls
of Neuse Road, Wake Forest, NC27587 (emoil: [e-mail]. Questions regarding this form or any of the
permit conditions may be directed to the USACE Project Manager below.
USACE Project Manager: David Bailey
USACE Field Office:
Email:
Raleigh Regulatory Field Office
US Army Corps of Engineers
3331 Heritage Trade Drive, Suite 105
Wake Forest, North Carolina 27587
Digitally signed by BAILEY.DAVID.E.1379283736
► � DN: r—US, o=U.S. Gavernment, ou=DoD, ou=PKl,
ou=USA, cn=BAILEY.DAVID.E.1379283736
Date: 2015.12.21 14;08:46 -OS'00'
USACE Project Manager Signature
December 21. 2015
Date of Signature
Current Wilmington District mitigation guidance, including information on mitigation ratios, functional assessments, and
mitigation bank location and availability, and credit classifications (including stream temperature and wetland groupings) is
available at http:/Oribits.usace.armv.mil.
Page 2 of 2
The Wilmington District is committed to providing the highest level of support to the public. To help us ensure we continue to do so, olease comolete the
Customer Satisfaction Survey located at our website at http://re�ulatorv.usacesurvev.com/ to complete the survey online.