20241011 Ver 1_PCN_FillableForm_v4-3_2-22-2024_20240725

Office Use Only
STATE
VIM o a
� Corps Action ID no. [Click to enter.] Date received: [Click to enter.]
I � DWR project no. [Click enter.] Date received: [Click to enter.]
Site Coordinates:
Latitude (DD.DDDDDD): 35.537128
NORTH CAROLINA Longitude (DD.DDDDDD): -76.621908
Environmental Quality
Water Resources Form Version 4.3, February 22, 2024
Pre-Construction Notification (PCN) Form
(Ver. 4.3, February 22, 2024)
For Nationwide Permits and Regional General Permits and corresponding Water Quality Certifications
Please note: fields marked with a red asterisk * are required. The form is not considered complete until all
mandatory questions are answered.
The PCN help document may be found at this link:
https://www.deg.nc.gov/water-resources/pcn-help-document-last-updated-1162024
Page 1 of 20 PCN Form Version 4.3-February 22,2024

A. Processing Information
County (counties)where project is located: * Choose one. Additional (if needed).
Is this an ARPA project? * ❑ Yes ❑x No
If yes, ARPA project number:
*The project number can be found on the"Letter of Intent to Fund"
(LOIF)or"Offer and Acceptance Letter". If you are unable to locate Click or tap here to enter text.
your DWI ARPA Funding Project Number,please contact Corey
Basinger at corey.basingera(�ncdenr.gov for further assistance.
Is this a NCDMS project? *
(Click yes only if NCDMS is the applicant or co- ❑ Yes ❑x No
applicant)
Is this a public transportation project?
(Publicly funded municipal, state, or federal road, rail, ❑ Yes ❑x No
or airport project)
Is this a NCDOT project? * ❑ Yes ❑x No
If yes, NCDOT TIP or state project number: Click to enter.
If yes, NCDOT WBS number: * Click to enter.
❑ Section 404 Permit(wetlands, streams, waters,
la. Type(s) of approval sought from the Corps: * Clean Water Act)
❑x Section 10 Permit (navigable waters, tidal
waters, Rivers and Harbors Act)
Has this PCN previously been submitted? * ❑ Yes ❑x No
Please provide the date of the previous submission. * Click to enter a date.
❑x Nationwide Permit(NWP)
1 b. What type(s) of permit(s)do you wish to seek
authorization? * El Regional General Permit (RGP)
❑ Standard (IP)
This form may be used to initiate the standard/ individual permit process with the USACE. Please contact your Corps
representative concerning submittals for standard permits. All required items can be included as attachments and
submitted with this form.
1c. Has the NWP or GP number been verified by the Corps? * ❑ Yes ❑x No
NWP number(s) (list all numbers ): Click to enter.
RGP number(s) (list all numbers ): Click to enter.
Are you a federal applicant? ❑ Yes ❑x No
If yes, please provide a statement concerning compliance with the Coastal Zone Management Act
Click to enter text.
1d. Type(s)of approval sought from DWR (check all that apply):
❑ 401 Water Quality Certification— Regular ❑ 401 Water Quality Certification— Express
❑ Non-404 Jurisdictional General Permit ❑x Riparian Buffer Authorization
❑ Individual 401 Water Quality Certification
Is this a courtesy copy notification ❑ Yes ❑ No
Page 2 of 20 PCN Form Version 4.3-February 22,2024

1e. Is this notification solely for the record because written approval is not required? *
For the record only for DWR 401 Certification: * ❑ Yes ❑x No
For the record only for Corps Permit: * ❑ Yes ❑x No
1f. Is this an after-the-fact permit/certification application? * ❑ Yes ❑x No
1g. Is payment into a mitigation bank or in-lieu fee program proposed for ❑ Yes ❑x No
mitigation of impacts?
If yes, attach the acceptance letter from mitigation bank or in-lieu fee program.
1 h. Is the project located in any of NC's twenty coastal counties? * ® Yes ❑ No
1 i. Is the project located within an NC DCM Area of Environmental ❑ Yes ❑x No ❑ Unknown
Concern (AEC)? *
1j. Is the project located in a designated trout watershed? * ❑ Yes ❑x No
If yes, you must attach a copy of the approval letter from the appropriate Wildlife Resource Commission Office.
Trout information may be found at this link: http://www.saw.usace.armV.miI/Missions/RegulatorV-Permit-
Program/AgencV-Coordination/Trout.aspx
Page 3 of 20 PCN Form Version 4.3-February 22,2024

B. Applicant Information
1a. Who is the primary contact?* Lynn Davis
1 b. Primary Contact Email: * [e-mail]
1 c. Primary Contact Phone: * (###)###-#### [phone]
1d. Who is applying for the permit/certification? * (check ❑ Owner 0 Applicant (other than owner)
all that apply)
1 e. Is there an agent/consultant for this project?* ❑ Yes 0 No
2. Landowner Information
2a. Name(s)on Recorded Deed: * Town of Belhaven
2b. Deed Book and Page No.: 2003 -4111
2c. Contact Person (for corporations): Lynn Davis
2d. Address '
Street Address: 315 E Main Street
Address line 2: Click to enter.
City: Belhaven
State/ Province/ Region: NC
Postal/Zip Code: 27810
Country: USA
2e. Telephone Number: * (###)###-#### [phone]
2f. Fax Number: (###)###-#### [phone]
2g. Email Address: * [e-mail]
3. Applicant Information (if different from owner)
3a. Name: * Click to enter.
3b. Business Name (if applicable): Click to enter.
3c. Address: *
Street Address: Click to enter.
Address line 2: Click to enter.
City: Click to enter.
State/ Province/ Region: Click to enter.
Postal/Zip Code: Click to enter.
Country Click to enter.
3d. Telephone Number: * (###)###-#### Click to enter.
3e Fax Number: (###)###-#### Click to enter.
3f. Email Address: * Click to enter.
Page 4 of 20 PCN Form Version 4.3-February 22,2024

4. Agent/Consultant (if applicable)
4a. Name: Click to enter.
4b. Business Name: Click to enter.
4c. Address:
Street Address: Click to enter.
Address line 2: Click to enter.
City: Click to enter.
State/ Province/ Region: Click to enter.
Postal/Zip Code: Click to enter.
Country: Click to enter.
4d. Telephone Number: (###)###-#### Click to enter.
4e Fax Number: (###)###-#### Click to enter.
4f. Email Address: Click to enter.
Agent Authorization Letter:
Attach a completed/signed agent authorization form or letter. A sample form may be found at this link:
https://www.saw.usace.army.mil/Missions/Regulatory-Permit-Prog ram/Perm its/2017-Nationwide-Permits/Pre-
construction-Notification/
Page 5 of 20 PCN Form Version 4.3-February 22,2024

C. Project Information and Prior Project History
1. Project Information
1a. Name of project: * Belhaven Harbor Park
1 b. Subdivision name (if appropriate): Click to enter.
1c. Nearest municipality/town: * Belhaven
2. Project Identification
2a. Property identification number(tax PIN or parcel ID): 7605-78-2861
2b. Property size (in acres): 0.842
2c. Project Address:
Street Address: 284 E Water Street
Address line 2: Click to enter.
City: Belhaven
State/ Province/ Region: NC
Postal/Zip Code: 27810
Country: USA
2d. Site coordinates in decimal degrees (using 4-6 digits Latitude (DD.DDDDDD): * 35.537128
after the decimal point): * Longitude (-DD.DDDDDD): *--76.621908
3. Surface Waters
3a. Name of nearest body of water to proposed project: * Pantego Creek
3b. Water Resources Classification of nearest receiving SC;NSW
water: *
The Surface Water Classification map may be found at this link:
https://experience.arcgis.com/experience/7073e9l 22ab74588b8c48ded34c3df55/
3c. In what river basin(s) is your project located? * Tar-Pamlico
Choose additional (if needed)
3d. Please provide the 12-digit HUC in which the project is 030201040305
located:
The Find Your HUC map may be found at this link:
https://ncdenr.maps.arcqis.com/apps/Publicinformation/index.html?appid=ad3a85aOc6d644aOb97cdO69db238ac3
Page 6 of 20 PCN Form Version 4.3-February 22,2024

4. Project Description and History
4a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of
this application: *
Vacant land with grass cover
4b. Have Corps permits or DWR certifications been obtained for this ❑ Yes ❑x No ❑ Unknown
project (including all prior phases) in the past? *
If yes, please give the DWR Certification number and/or Corps [Click to enter.]
Action ID (ex. SAW-0000-00000): jClick to enter.]
Attach any pertinent project history documentation
4b2. Is any portion of the work already complete? * ❑ Yes ❑x No
If yes, describe the completed work.
Click to enter text.
4c. List of other certifications or approvals/denials received from other federal, state or local agencies for work
described in this application not related to the 404 or 401.
Click to enter text.
4d. Attach an 8'/2 x 11" excerpt from the most recent version of the USGS topographic map indicating the location of
the project site.
4e. Attach an 8'/2 x 11" excerpt from the most recent version of the published County NRCS Soil Survey map
depicting the project site.
4f. List the total estimated acreage of all existing wetlands on the Click to enter. acres
property:
4g. List the total estimated linear feet of all existing streams (intermittent Click to enter. linear feet
and perennial)on the property:
-T
4g1. List the total estimated acreage of all existing open waters on the Click to enter. acres
property:
4h. Explain the purpose of the proposed project: *
Construct 24' x 50' stage and bathhouse area for the Town of Belhaven
4i. Describe the overall project in detail, including the type of equipment to be used:
Click to enter text.
4j. Attach project drawings/site diagrams/depictions of impact areas for the proposed project.
4k. Will this activity involve dredging in wetlands or waters? * ❑ Yes ❑x No
If yes, describe the type of dredging, the composition of the dredged material, and the locations of disposal area.
Click to enter text.
Page 7 of 20 PCN Form Version 4.3-February 22,2024

5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or in ❑ Yes ❑x No ❑ Unknown
proposed impact areas?
Comments:
Click to enter text.
5b. If the Corps made a jurisdictional determination, ❑ Preliminary ❑ Approved ❑ Emailed concurrence
what type of determination was made? * ❑ Not Verified ❑ Unknown ❑x n/a
Corps AID number(ex. SAW-0000-00000): Click to enter.
Name (if known): Click to enter.
5c. If 5a is yes, who delineated the jurisdictional Agency/Consultant Company: Click to enter.
areas?
Other: Click to enter.
5d. List the dates of the Corps jurisdictional determination or State determination if a determination was made by
either agency.
Click to enter.
5d1. Attach jurisdictional determinations.
6. Future Project Plans
6a. Is this a phased project? ❑ Yes ❑x No
6b. If yes, explain.
Click to enter.
Are any other NWP(s), regional general permit(s), or individual permit(s) used, or intended to be used, to
authorize any part of the proposed project or related activity?This includes other separate and distant crossings
for linear projects that require Department of the Army authorization but don't require pre-construction
notification.
Click to enter.
7. Addresses of adjoining property owners, lessees, etc. whose property adjoins the waterbody(if more than can be
entered here, please attach a supplemental list)
Click to enter.
8. Scheduling of activity:
Click to enter.
Page 8 of 20 PCN Form Version 4.3-February 22,2024

D. Proposed Impacts Inventory
1. Impacts Summary
❑ Wetlands ❑ Streams-tributaries
1a. Where are the impacts associated with your project ❑x Buffers ❑ Open Waters
(check all that apply):
❑ Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, complete this table for each wetland area impacted.
2a. 2a1. 2b. 2c. 2d. 2e. 2f. 2g.
Site#* Impact Impact Wetland Type* Wetland Name* Forested Jurisdiction Impact Area
Reason/Type* Duration* ?* Type* (ac)*
W1 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W2 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W3 Choose one Temp/Perm Choose one Click to enter Y/N Choose one Click to enter
W4 Choose one Temp/Perm Choose one Click to enter Y/N Choose one Click to enter
W5 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W6 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W7 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W8 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W9 Choose one Temp/Perm Choose one Click to enter Y/N Choose one Click to enter
W10 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W11 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W12 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W13 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W14 Choose one Temp/Perm Choose one Click to enter Y/N Choose one Click to enter
W15 Choose one Temp/Perm Choose one Click to enter Y/N Choose one Click to enter
2g1. Total temporary wetland impacts Click to enter. ac
2g2. Total permanent wetland impacts Click to enter. ac
2g3. Total wetland impacts Click to enter. ac
2h. Type(s) of material being discharged and the amount of each type in cubic yards:
Click to enter text.
2i. Comments:
Click to enter text.
Page 9 of 20 PCN Form Version 4.3-February 22,2024

3. Stream Impacts
If there are perennial or intermittent stream/tributary impacts (including temporary impacts) proposed on the site,
complete this table for all stream/tributary sites impacted.
**All Perennial or Intermittent streams must be verified by DWR or delegated local government
3a 3b. 3c. 3d. 3e. 3f. 3g. 3h.
Site#* Impact Impact Impact Type* Stream Name* Stream Jurisdiction Stream Width Impact length
Reason* Duration* Type* Type* (avg ft)* (linear ft) *
S1 Click to enter Temp/Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S2 Click to enter Temp/Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S3 Click to enter Temp/Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S4 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S5 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S6 Click to enter Temp/Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S7 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S8 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S9 Click to enter Temp/Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S10 Click to enter Temp/Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S11 Click to enter Temp/Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S12 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S13 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S14 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S15 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S16 Click to enter Temp/Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S17 Click to enter Temp/Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S18 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S19 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S20 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
3i1. Total jurisdictional ditch Click to enter. linear ft
impact:
M. Total permanent stream Click to enter. linear ft
impacts:
M. Total temporary stream Click to enter. linear ft
impacts:
34. Total stream and ditch Click to enter. linear ft
impacts:
3j. Comments:
Click to enter.
Page 10 of 20 PCN Form Version 4.3-February 22,2024

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., individually list all open water impacts in the table below.
4a. 4a1. 4b. 4c. 4d. 4e. 4f.
Site#* Impact Reason Impact Waterbody Name* Activity Type* Waterbody Impact area
Duration* Type* (ac)*
01 Click to enter. Temp/Perm Click to enter. Choose one Choose one Click to enter.
02 Click to enter. Temp/Perm Click to enter. Choose one Choose one Click to enter.
03 Click to enter. Temp/Perm Click to enter. Choose one Choose one Click to enter.
04 Click to enter. Temp/Perm Click to enter. Choose one Choose one Click to enter.
05 Click to enter. Temp/Perm Click to enter. Choose one I Choose one Click to enter.
4g. Total temporary open water impacts Click to enter. ac
4g. Total permanent open water impacts Click to enter. ac
4g. Total open water impacts Click to enter. ac
4h. Comments:
Click to enter.
5. Pond or Lake Construction
If pond or lake construction is proposed, complete the table below. (*This does NOT include offline stormwater
management ponds.)
5a. 5b. 5c. 5d. 5e.
Pond ID Proposed use or Wetland Impacts (ac) Stream Impacts (ft) Upland
# purpose of pond Flooded Filled Excavated Flooded Filled Excavated Impacts (ac)
P1 Choose one Click to Click to Click to Click to Click to Click to Click to
enter. enter. enter. enter. enter. enter. entr
P2 Choose one Click to Click to Click to Click to Click to Click to Click to
enter. enter. enter. enter. enter. enter. enter.
P3 Choose one Click to Click to Click to Click to Click to Click to Click to
enter. enter. enter. enter. enter. enter. enter.
5f. Total Click to Click to Click to Click to Click to Click to Click to
enter. enter. enter. enter. enter. enter. enter.
5g. Comments:
Click to enter.
5h. Is a dam high hazard permit required? ❑ Yes ❑ No
If yes, permit ID no.: Click to enter.
5i. Expected pond surface area (acres): Click to enter.
5j. Size of pond watershed (acres): Click to enter.
5k. Method of construction:
Click to enter.
Page 11 of 20 PCN Form Version 4.3-February 22,2024

6. Buffer Impacts (DWR requirement)
If project will impact a protected riparian buffer, then complete the chart below. Individually list all buffer impacts.
❑ Neuse ❑x Tar-Pamlico ❑ Catawba
6a. Project is in which protected basin(s)? ❑ Jordan ❑ Goose Creek ❑ Randleman
* (Check all that apply.)
❑ Other: Click to enter.
6b. 6c. 6d. 6e. 6f. 6g.
Site#* Impact Type* Impact Duration* Stream Name* Buffer Zone 1 Impact* Zone 2 Impact*
Mitigation (sq ft) (sq ft)
Required?*
B1 Other Permanent Pantego Creek No Click to enter. 883
B2 Temp. Erosion Temporary Pantego Creek No 1511 1539
Control
B3 Choose one Temp/Perm Click to enter. Y/N Click to enter. Click to enter.
B4 Choose one Temp/Perm Click to enter. Y/N Click to enter. Click to enter.
B5 Choose one Temp/Perm Click to enter. Y/N Click to enter. Click to enter.
B6 Choose one Temp/Perm Click to enter. Y/N Click to enter. Click to enter.
B7 Choose one Temp/Perm Click to enter. Y/N Click to enter. Click to enter.
B8 Choose one Temp/Perm Click to enter. Y/N Click to enter. Click to enter.
B9 Choose one Temp/Perm Click to enter. Y/N Click to enter. Click to enter.
B10 Choose one Temp/Perm Click to enter. Y/N Click to enter. Click to enter.
1311 Choose one Temp/Perm Click to enter. Y/N Click to enter. Click to enter.
B12 Choose one Temp/Perm Click to enter. Y/N Click to enter. Click to enter.
B13 Choose one Temp/Perm Click to enter. Y/N Click to enter. Click to enter.
B14 Choose one Temp/Perm Click to enter. Y/N Click to enter. Click to enter.
B15 Choose one Temp/Perm Click to enter. Y/N Click to enter. Click to enter.
B16 Choose one Temp/Perm Click to enter. Y/N Click to enter. Click to enter.
B17 Choose one Temp/Perm Click to enter. Y/N Click to enter. Click to enter.
B18 Choose one Temp/Perm Click to enter. Y/N Click to enter. Click to enter.
B19 Choose one Temp/Perm Click to enter. Y/N Click to enter. Click to enter.
B20 Choose one Temp/Perm Click to enter. Y/N Click to enter. Click to enter.
6h. Total temporary impacts: Zone 1: Click to enter. sq ft Zone 2: Click to enter. sq ft
6h. Total permanent impacts: Zone 1: Click to enter. sq ft Zone 2: Click to enter. sq ft
6h. Total combined buffer impacts: Zone 1: Click to enter. sq ft Zone 2: Click to enter. sq ft
6i. Comments:
Click to enter.
Please attach supporting documentation (impact maps, plan sheets, etc.)for the proposed project.
Page 12 of 20 PCN Form Version 4.3-February 22,2024

E. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts through project design:
Click to enter.
1 b. Specifically describe measures taken to avoid or minimize proposed impacts through construction techniques:
Click to enter.
2. Compensatory Mitigation for Impacts to Waters of the U.S.,Waters of the State, or Riparian Buffers
2a. If compensatory mitigation is required, by whom is it required? * ❑ DWR ❑ Corps
(check all that apply)
2b. If yes, which mitigation option(s)will be used for this ❑ Mitigation Bank
project? * (check all that apply) ❑ In Lieu Fee Program
❑ Permittee Responsible Mitigation
3. Complete if using a Mitigation Bank (Must satisfy NC General Statute143-214.11 (d1).)
3a. Name of mitigation bank: Click to enter.
3b. Credits purchased/requested: Type: Choose one Quantity Click to enter.
Type: Choose one Quantity Click to enter.
Type: Choose one Quantity Click to enter.
Attach receipt and/or approval letter.
3c. Comments:
Click to enter.
4. Complete if Using an In Lieu Fee Program
4a. Attach approval letter from in lieu fee program.
4b. Stream mitigation requested: Click to enter. linear feet
4c. If using stream mitigation, what is the stream temperature: Choose one
NC Stream Temperature Classification Maps can be found under the Mitigation Concepts tab on the Wilmington
District's RIBITS website: (Please use the filter and select Wilmington district)
https://ribits.ops.usace.army.mil/ords/f2p=107.2::::::
4d. Buffer mitigation requested (DWR only): Click to enter. square feet
4e. Riparian wetland mitigation requested: Click to enter. acres
4f. Non-riparian wetland mitigation requested: Click to enter. acres
4g. Coastal (tidal)wetland mitigation requested: Click to enter. acres
4h. Comments:
Click to enter.
Page 13 of 20 PCN Form Version 4.3-February 22,2024

5. Complete if Providing a Permittee Responsible Mitigation Plan
5a. If proposing a permittee responsible mitigation plan, provide a description of the proposed mitigation plan,
including mitigation credits generated.
Click to enter.
5b. Attach mitigation plan/documentation.
6. Buffer Mitigation (State Regulated Riparian Buffer Rules)— DWR requirement
6a. Will the project result in an impact within a protected riparian buffer ❑ Yes ❑ No
that requires buffer mitigation?
If yes, please complete this entire section— please contact DWR for more information.
6b. If yes, identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required in the table below.
6c. 6d. 6e.
Zone Reason for impact Total impact Multiplier Required mitigation
(square feet) (square feet)
Zone 1 Click to enter. Click to enter. Choose one Click to enter.
Zone 2 Click to enter. Click to enter. Choose one Click to enter.
6f. Total buffer mitigation required Click to enter.
6g. If buffer mitigation is required, is payment to a mitigation bank or ❑ Yes ❑ No
NC Division of Mitigation Services proposed?
6h. If yes, attach the acceptance letter from the mitigation bank or NC Division of Mitigation Services.
6i. Comments:
Click to enter.
Page 14 of 20 PCN Form Version 4.3-February 22,2024

F. Stormwater Management and Diffuse Flow Plan (DWR requirement)
1. Diffuse Flow Plan
1a. Does the project include or is it adjacent to protected riparian buffers ® Yes ❑ No
identified within one of the NC Riparian Buffer Protection Rules?
1 b. All buffer impacts and high ground impacts require diffuse flow or other form of stormwater treatment. If the
project is subject to a state implemented riparian buffer protection program, include a plan that fully documents
how diffuse/dispersed flow will be maintained.
All Stormwater Control Measures (SCM) must be designed in accordance with the NC Stormwater Design
Manual (https://deg.nc.gov/about/divisions/energV-mineral-land-resources/energV-mineral-land-permit-
guidance/stormwater-bmp-manual).
Associated supplement forms and other documentation must be provided.
❑ Level Spreader
What Type of SCM are you ❑ Vegetated Conveyance (lower seasonal high water table- SHWT)
providing? ❑ Wetland Swale (higher SHWT)
(Check all that apply) ❑ Other SCM that removes minimum 30% nitrogen
❑x Proposed project will not create concentrated stormwater flow through the
buffer
For a list of options to meet the diffuse flow requirements, click here.
Attach diffuse flow documentation.
2. Stormwater Management Plan
2a. Is this an NCDOT project subject to compliance with NCDOT's
Individual NPDES permit NCS000250? * El Yes No
2b. Does this project meet the requirements for low density projects as
defined in 15A NCAC 02H .1003(2)? * ❑x Yes El No
To look up low density requirements, click here:
http://reports.oah.state.nc.us/ncac/title%2015a%20-%2Oenvironmental%20Quality/chapter%2002%20-
%20environmental%20management/subchapter%20h/15a%20ncac%2002h%20.1003.pdf
2c. Does this project have a stormwater management plan (SMP) ❑ Yes ❑ No
reviewed and approved under a state stormwater program or state-
approved local government stormwater program? * ❑x n/a—project disturbs < 1 acre
Note: Projects that have vested rights, exemptions, or grandfathering from state or locally implemented
stormwater programs or projects that satisfy state or locally-implemented stormwater programs through use of
community in-lieu programs should answer"no" to this question.
2d. Which of the following stormwater management program(s) apply? ❑ Local Government
(Check all that apply.)* ❑ State
If you have local government approval, please include the SMP on their overall impact map.
Local Government Stormwater Programs * ❑ Phase II ❑ USMP
❑ NSW ❑ Water Supply
Page 15 of 20 PCN Form Version 4.3-February 22,2024

Please identify which local government stormwater program you are using.
Click to enter.
State Stormwater Programs * ❑ Phase II ❑ HQW or ORW
❑ Coastal Counties ❑ Other
Comments:
Click to enter.
Page 16 of 20 PCN Form Version 4.3-February 22,2024

G. Supplementary Information
1. Environmental Documentation
1a. Does the project involve an expenditure of public (federal/state/local) ❑ Yes ❑ No
funds or the 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 (North Carolina) Environmental El Yes El No
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 ❑ Yes ❑ No
NEPA or SEPA final approval letter.)
Comments:
Click to enter.
2. Violations (DWR Requirement)
2a. Is the site in violation of DWR Water Quality Certification Rules (15A
NCAC 2H .0500), Isolated Wetland Rules (15A NCAC 2H .1300),
Federally Non-Jurisdictional Wetlands/Classified Surface Waters ❑ Yes ❑x No
(15A NCAC 2H. 1400) DWR Surface Water or Wetland Standards or
Riparian Buffer Rules (15A NCAC 2B .0200)? *
2b. If you answered "yes" to the above question, provide an explanation of the violation(s):
Click to enter.
3. Cumulative Impacts (DWR Requirement)
3a. Will this project(based on past and reasonably anticipated future
impacts) result in additional development, which could impact nearby ® Yes ❑ No
downstream water quality? *
3b. If you answered "no", provide a short narrative description:
Click to enter.
3c. If yes, provide a qualitative or quantitative cumulative impact analysis in accordance with the most recent DWR
policy. (Attach .pdf)
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project? * ❑ Yes ❑x No ❑ N/A
4b. If yes, describe in detail the treatment methods and dispositions (non-discharge or discharge) of wastewater
generated from the proposed project. If the wastewater will be treated at a treatment plant, list the capacity
available at that plant.
Click to enter.
Page 17 of 20 PCN Form Version 4.3-February 22,2024

5. Endangered Species and Designated Critical Habitat(Corps Requirement)
5a. Will this project occur in or near an area with federally protected ® Yes ❑ No
species or habitat? (IPAC weblink: https://www.fws.gov/ipac/ffws.govl)
5b. Have you checked with the USFWS concerning Endangered Species ❑ Yes ❑x No
Act impacts? *
5c. If yes, indicate the USFWS Field Office you have contacted. Choose one
5d. Is another federal agency involved? * ❑ Yes ❑x No ❑ Unknown
If yes, which federal agency? Click to enter.
5e. Is this a DOT project located within Divisions 1-8? * ❑ Yes ❑x No
5f. Will you cut any trees in order to conduct the work in waters of the
U.S.? * El Yes El No
5g. Does this project involve bridge maintenance or removal? * ❑ Yes ❑x No
5g1. If yes, have you inspected the bridge for signs of bat use such as
staining, guano, bats, etc.? Representative photos of signs of bat use ❑ Yes ❑ No
can be found in the NLEB SLOPES, Appendix F, pages 3-7.
Representative photos of signs of bat use can be found in the NLEB SLOPES, Appendix F, pages 3-7. Link to
NLEB SLOPES document: http://saw-reg.usace.army.mil/NLEB/1-30-17-signed NLEB-SLOPES&apps.pdf
If you answered yes to 5g1, did you discover any signs of bat use? * ❑ Yes ❑ No ❑ Unknown
If yes, please show the location of the bridge on the permit drawings/project plans
5h. Does this project involve the construction/ installation of a wind
turbine(s)? * El Yes 0 No
If yes, please show the location of the wind turbine(s) on the permit drawings/ project plans (attach .pdf)
5i. Does this project involve blasting and /or other percussive activities
that will be conducted by machines, such as jackhammers, ® Yes ❑ No
mechanized pile drivers, etc.? *
If yes, please provide details to include type of percussive activity, purpose, duration, and specific location of this
activity on the property (attach .pdf)
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated
Critical Habitat? *
USFWS IPAC website
Attach consultation documentation.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as
an Essential Fish Habitat? * El Yes El No
Is there submerged aquatic vegetation (SAV) around
the project vicinity? * El Yes No El Unknown
Will this project affect submerged aquatic vegetation? * ❑ Yes 0 No ❑ Unknown
Page 18 of 20 PCN Form Version 4.3-February 22,2024

Explain: Click to enter.
6b. What data source(s)did you use to determine whether your site would impact Essential Fish Habitat?
Click to enter.
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
Link to the State Historic Preservation Office Historic Properties Map (does not include archaeological data):
http://gis.ncdcr.gov/hpoweb/
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 status (e.g., National Historic Trust designation or El Yes ❑x No
properties significant in North Carolina history and archaeology)?
7b. What data source(s) did you use to determine whether your site would impact historic or archeological
resources? *
Click to enter.
7c. Attach historic or prehistoric documentation.
8. Flood Zone Designation (Corps Requirement)
Link to the FEMA Floodplain Maps: https://msc.fema.gov/portal/search
8a. Will this project occur in a FEMA-designated 100-year floodplain? * ® Yes ❑ No
8b. If yes, explain how the project meets FEMA requirements.
Structures located above base flood elevation
8c. What source(s) did you use to make the floodplain determination?
FEMA National Flood Insurance Program map
H. Miscellaneous
Comments:
Click to enter.
Attach pertinent documentation or attachments not previously requested
Page 19 of 20 PCN Form Version 4.3-February 22,2024

7/18/24, 10:44 AM image001.png
I. Signature"
r By checking the box and signing below, I, as the project proponent, certify to the following:
The project proponent hereby certifies that all information contained herein is true, accurate,and complete,to
the best of my knowledge and belief,
The project proponent hereby requests that the certifying authority review and take action on this CWWA 401
certification request within the applicable reasonable period of time;
+ The project proponent hereby agrees that submission of this PCN form is a"transaction"subject to Chapter
66,Article 40 of the NC General Statutes(the"Uniform Electronic Transactions Act");
The project proponent hereby agrees to conduct this transaction by electronic means pursuant to Chapter 66,
Article 40 of the NC General Statutes(the'Uniform Electronic Transactions Act");
The project proponent hereby understands that an electronic signature has the same legal effect and can be
enforced in the same way as a written signature;AND
As the project proponent, I intend to electronically sign and submit the PCNlonline form.
Full Name:" Click to eater. Yl r) WV • l�Gt�t 5.
Signature:g Click to eater.
Date: Click to enter. r
hftps://mail.google.com/mail/u/0/?tab=rm&ogbl#inbox/FMfcgzQVxbrSrgmBBgvtRrSqfMmNPRpl?projector=l 1/1