20170639 Ver 1_SR 1333, PCN 2017_20170524

Office Use Only:
Corps action ID no.
DWQ prqject no.
Form Version 1.3 Dec 1 D 2008
Pre-Construction Notificafion C Form
A. A lica�nt Informafiion
1. Processing
1a. Type(s) of approval sought from the
cQ�$; � Sectian 404 Permit ❑ 5ection 10 Permit
1 b. Specify NatFonwide Permit (NWP} number: 3 or General Permit (GP} number:
1c. Has the NWP or GP number heen �erified by the Corps? ❑ Yes � No
1 d. Type{s) of approvaf sought fram the DWQ (check a!I that apply):
� 401 Water Quafity Certification — Regular ❑ P�on-404 Jurisdictional G�nera! Permit
❑ 401 Water Quality Certification — Expeess ❑ Riparian BU#Fer Ae�thorization
1 e. !s this raotification solely for the record For the record anly for DWQ 4Q9 For the record only fnr Corps Permit:
because wriiten appraval is not required? Certifica#ion:
❑ Yes � No � Yes ❑ No
1f. fs payment intp a mitigation bank or in-fieu fee program proposed far rni#igation � Yes � No
of impacts? If so, attach the acceptance letter from mitigation bank or in-Geu
fee program.
1g. Is the project located in any af NC's twenty coa$tal counties. If yes, answer '!h ❑ Yes � No
below.
1 h. Is t�e pro}ect located wiihin a NC DGM Area af En�ironmentai Concern (AEC)? ❑ Yes � Na
2. ProJect Information
2a. Name af project: SR 1333, Grover Cockerham Road, Shoulder failure
2b. County: Surry
2c. IVearest municipality 1 town: Mauntain Park
2d. Subdivisian name:
2e. NCDOT only, T.I.P, or state �.� 2�8627
project no:
3. Owner Information
3a. Name(s) on Recorded Deed: NCDQT
3b. Deed Book and Page No.
3c. Respansible Rarty (for LLC if
applicable):
3d. Street address: 801 Siatesvilfe Road
3e. City, state, zip: Nor#h Wilkesboro, NC 28659
3f. Telephone no.: 336-903-9202
3g. Fax no.: 336-667-4549
3h. Emaii address: hslaughter c�ncdot.go�
Page 1 of 40
PCN Form — Version 1.3 December 9 D, 2Q08 Version

4. Aqplicant Information (ff cfiiferent from owner)
4a. Applican� is: ❑ Agen# ❑ Other, specify:
4b. Name:
4c. Bus9ness r+ame
{if applic�ble).
4�d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. AgentlConsultant tnformatian (if applieable)
5a. Name:
5b. �usiness nam�
(if applicablej:
5c. Street address:
5d. City, state, zip:
5�. T�lephone no.:
5f. Faac no.:
5g. Email address:
Page 2 c�f 1 a
PCN Farm -- Version 1.3 December 't 0, 20D8 Version

B. Project Information and Prior Project History
1. Properly Identificatian
1a. Property identification na. (ta�c PIN or parcel ID):
1b. Site coordinates (in decimal degrees): Latitude: 36.41222 Longitude: - 80.84940
(DD.DDa�DD} (-DD.Rf3DDDD)
1 c. Property size: 0.1 acres
2. SurFace Waters
2a. Name of nearest body of wat�r (stream, ri�er, etc.} to Mitchel River
praposed project:
2b. Water Quality Classifrcation of nearest recei�ing water: C; Trout, ORW
2c. River basin: Yadkin
3. Project Description
3a. Describe the existing conditions an the site and the general land use in the vicinity of the project at the time of this
applicatian:
Unpaved secondary road in a rural area..
3b. List the total estima#ed acreage of all existing rwe#lands on the praperty:
0 acres
3c. List the total estimated linear feet of alk existing streams (intermittent and perennial) on the property:
100 linear feet
3d. Explain the purpose of the proposed project:
Bank Stabilizatian
3e. I�escribe the overall project in detail, including the type of equipment to be used:
Track hoe artd dump #rucks
4. .lurisdictional Determinations
4a, Fia�e jurisdictional wetlanci or stream determinations by the
Corps or State been requested or obtained for this property 1
praject (incfuding all prior phases) in ihe past? ❑ Yes �f Na ❑ Unknown
Comments:
4b. If the Corps made the jur�sdictiorral determination, +nrhat typ+�
of determination was rnade? ❑�r�liminary ❑ Finaf
4c. If yes, wl-io delinea#ed the jurisdictional areas? AgencylConsultant Company:
Name (if known}_ pther:
4d. If yes, list the da#es of the Corps jurisdictional determinations or State determinations and attach documentation.
5. Project History
5a. Have permits or certifrcations bee� requested or obtained for � Yes � No ❑ Unknown
this project (including all prior phases) in the past?
5b. If yes, explain in detail according to "help file" instruciions.
6. Future Project Plans
6a. Is this a phased project? ❑ Yes � No
6b. If yes, explain.
Page 3 af 10
PCN Form — Version 1.3 December 10, 2008 Version

C. Praposed Impacts 4nventary
1. fmpacts 5ummary
1 a. Which sect�ons were completed below for your praject (check aEl that apply}:
❑ Wetlands � Streams - tributaries ❑ BufFers
❑ Open Waters ❑ Pond Construction
2, Wetland Impacts
If th�re are wetland impacts proposed on the site, then complete this questian for each wetland area impacted.
2a. 2b. 2c_ 2d, 2e_ 2f.
We�and impac# Type of jurisdiction
number — 7ype af impact Type of we#land Forested (Corps - 404, 10 Area of impact
Permanent (P) w (if known} DWQ — non-�04, ather} (acres)
Tem ara
W1 ❑ P � T ❑ Yes ❑ Gor'ps
❑ No ❑ DWQ
W2 ❑ P � T ❑�`eS ❑ Corps
❑ Na ❑ DWQ
W3 ❑ P❑ T ❑ Yes ❑ Corps
❑ No ❑ DWQ
W� ❑ P ��. ❑ Yes ❑ Corps
❑ Np ❑ DWQ
W� � P� T ❑ Yes ❑ Corps
❑ No ❑ DWQ
w� ��, � T ❑ Yes ❑ Corps
❑ No � DWQ
2g. Total wetland impaets
2h, Comments:
3. Stream tmpacts
If there are per�nnial or intermittent stream impac#s (including temporary impaetsj proposed on the site, then complete this
question for all stream sites impacted.
3a. 3b. 3c. 3d. 3e. 3f. 3g.
Stream impact Type vf impact Stream name Perennial Type of jurisdiction Average Impact
number - PER ar
( ) {Corps - 4Q4, 10 stream length
Permaneni (P) or intermittent DWQ — non-404, width (linear
Temporary (7� {���? other) (feet) fieet)
5,� �� ��- Riprap Bank Mitchel Ri�er ���R � Corps ga 7a
Siabilization ❑ INT � DWQ
52 ❑ P❑ T ❑ PER ❑ Corps
❑ INT ❑ p1NQ
S3 ❑ P � T ❑ PER ❑ Corps
❑ INT ❑ DWQ
54 ❑ P❑ T ❑ PER ❑ Corps
❑ INT ❑ DWQ
S5 ❑ P ❑ T ❑ ��R ❑ Corps
❑ INT ❑ DWQ
S6 ❑ P[] T ❑ PER ❑ Corps
❑ INT � DWQ
3h. Total stream and tri�►utary impacts 70
3i. Comments:
Rage 4 af 10
PCN Form — Version 'f.3 December 1Q 2008 Version

4. Open Water Impacts
If there are proposed impacts to lakes, ponds, es#uaries, tribu#aries, sounds, the Atlan#ic Qcean, ar any other op�n water of
the U.S. then indir►idually list all open water impacts below.
4a. 4b. 4c. 4d. 4e.
Open water Name of waterbody
impact number — (if applicable) Type af irttpact Waterbody type Area of impact (acres)
Permanent {P} or
Tem ora
01 ❑R❑T
02 ❑P�]T
U3 ❑P�T
04 ❑P�7
4f. Total open water impacts
4g. Comments:
5. Pond ar Lake Constructian
If ond or lake construction ro osed, then cam lete the chari below.
5a. 5b. 5c. 5d. 5e.
Wetland Impacts (acres) Strearri fmpacts (feet) Upland
Pond ID proposed use or purpose (acres)
number of pond
Flooded F�lled Exca�ated Flooded �illed Excavated Flooded
P1
P2
5% Total
5g. Comments: NIA
5h. Is a dam high hazard permit required?
❑ Yes � No I�€ yes, permit ID no:
5i. Expected pond surtace area (acres):
5j. Size of por�d watershed (acres):
5k. Method of construction:
6. Buffer Impacts (for DWQ}
If project ruil! impact a protected riparian buffer, then complete #he chart below. If yes, then individually list ail buff�r impacts
below. if an impac#s re uire miti ation, then ou MUST fill aut Section D of this form.
6a.
❑ Neuse ❑ Tar-Pamlico ❑ Qther:
Project is in which protected basin? ❑ Gatawba ❑ Randieman
6b. 6c. 6d. 6e. 6f. 6g.
Buffer impact
number -- Reason Buffer Zone 1 impact Zone 2 impact
Permanent (P) or for Stream name mitigation (square feet} (square feet}
Tem ora im act re uir�?
81 ❑P�T ❑Yes
❑ No
B2 ❑ P❑ T Q Yes
❑ Na
63 ❑P❑T ❑Yes
❑ No
5h. Tota1 buffer impacts
6i. Gomments:
�age 5 of 10
PCN Form — Versian 1_3 �ecember 10, 2008 Version

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specfically describe measures iaken to avacf or minimize the proposed impacts in d�signin� project.
Impact area wili be the minimum needed to stabilize the shaufder.
1 b. Specifically describe measures taken ta avaid ar minimixe the praposed irnpacts ihrough construction techniques.
All appropriate BMPs will be used during construction.
2. Compensatory Mitigation for Impacts ta Waters of the U.S. or Waters of th� State
2a. Does the project require Compensatary Mitigation for ❑ Yes � No
impacts to Waters of the U.S. or Waters of the State?
Zb. If yes, mitigation is required by (check all that apply); ❑ QWQ ❑ Corps
❑ Mi#igatian bank
2c. If y�s, which mitigation option wiil be used for this � Payment to �n-lieu fee program
projeci?
❑ Permittee Respansible Mitigation
3. Carnplete if Llsing a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receip# and letter} Type Quantity
3c. Gomments:
4. Complete if Making a Payrrient to In-lieu Fee Program
4a. Approval !ei#er from in-lieu fee pragram is attached. ❑ Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature: ❑ warm [] eooi ❑cold
4d. Buffer rnitigation requested (DWQ only)_ square feet
4e. Riparian wetland mitigation requested: acres
4f. Non-riparian wetland mitigation requested: acres
4g. Coastal (tidal) wetland mitigation requested: aeres
4h. Comments:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a_ If using a perrnittee responsible rnitigation plan, pro�ide a description af the proposed mitigation plan.
Page 6 af 1 D
PCN Form — V�rsion 1.3 December 1�, 2flQ8 Version

8. BufFer Mitiga#ion (S#ate Regulated Rlparian Buffer Rules) — required by DWQ
fia. Will the proj� result in an impact within a protected riparian buffer thai requires ❑ Yes � No
buffer mitigation?
6b. If yes, then idan#ify 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 irr�pact Tot�l impact Mu�tip�ier Required mitigation
(square feet} (square feet)
Zone 1 3(2 far Gatawi�a)
Zone 2 1.5
6f. Total bufFer mftigatinn required:
6g. If buffer mitigation is required, discuss what type of mitigation is praposed (e,g., payment to pri�ate rnitigatior� bank,
permittee respansible riparian buffer restoration, payment irtto an approved in-lieu fee fund).
6h. Cnmments:
Page 7 of � 0
PCN Form — Version 9_3 December 10, 20Q8 Version

E. Stormwa#er Management and Diffuse Fiow Plan {required by DWQ)
1. DifFuse Flaw P1an
1a. Daes the project include or is it adjacent to protected riparian buffers identifed � Yes � No
within one of the NC Riparian Buffer Protectian Rules?
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
Camments: ❑ Yes ❑ I�o
2. Stormwater Mana ement Plan
2a. What is the averall perc�nt imperviausness of this project? %
2b. Daes this proje�ct require a Stormwater Management Plan? ❑ Yes ❑ No
2c. If this prajec# DOES NOT require a Starmwater Managernent Plan, explain why:
2d. if this project DOES require a Stormwater Management Plan, ther� �rovide a brief, narrati�e description of the plan;
❑ Certifed Local Gavemment
2e. Who wil! be responsible for the review of the Stormwater Management PIan7 ❑ DWQ Stormwater Program
❑ DWQ 4D1 Unit
3. Certified local Government Stormwater Review
3a. In which locai ga�emment's jucisdicction is this project?
❑ Phase II
3b. Which o# the follo►n�ng locally-�mplemented stormvuater managetnent programs ❑ N�W
apply (check all that apply): � ���p
❑ Water Suppiy Wate+�shed
❑ Other:
3c. Has the appraved Stormwater Management Plan with proof of approvai been ❑ Yes ❑ No
attached?
4. DWQ Stormwater Pro ram Review
❑ Caastal counties
❑ �aw
4a_ Which of the following state-implemented siormwafer management pragrams apply � ORW
{check all that apply):
❑ Session Law 2006-246
❑ 4ther:
4b. Has the apprar�ed Starmwater Management Plan wi� praof af approval been
attached? ❑ Yes ❑ No
5. DWQ 40�1 Unit Stormwater Review
5a. Does the Stormwater Management Plan mest the appropriate requirements? � Y�$ ��Q
5b. Have all of the 401 Unit submittal requirements been rnet? ❑ Yes ❑ Na
Page $ of 1 Q
PGN Form — Version 1.3 December 10, 2008 Version

F. Supplementary Information
1. Environmental Docamentation (DWQ Ftequirement}
9a. Does the praject inValve an expenditure of pubGc (federal/statellocal} funds �or �e � yes ❑ No
use of public {federaUs#ate) land?
1b. if you answered "yes" to the above, does the project require preparation of an
enr�iron►nentat docum�nt pursuant ta tt�e requirements of the IVational or State ❑ Yes � Na
(North Carolina} En�rironmental Policy Act {NEPA/S�PA)?
1 c. If you answered "yes" to the abo+re, has #he document re�iew been finafized by the
State Clearing House? (If so, attach a copy af the NEPA or SEPA final approval
letter.} ❑ Yes ❑ No
Camments:
2, Violations (DWQ Requiremeni)
2a Is the site in �iolation of pWQ Wetland Rules (15A f�CAC 2H .4504j, Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Sur�ace Water or Wetland Stanciards, ❑ Yes � No
or Riparian Buffer Rules (� SA NCAC 2B .0200)?
2b. !s this an after-the-fact perrni# application? ❑ Yes � IVo
2c. If yflu answered "yes" #o ane or both of the sba�e questions, provide an explar�ation ai the vioiation(s):
3. Cumulati�e Impaets (DWQ Requirement)
3a. Will this projeet (based on past and reasonably anticipated future impacts) result in � Yes � No
additional de�elopment, which couid impact nearby downstream water quality?
3b. If you answered "yes" to the above, submit a qualitati�e or quantitati�e cumufati�e impact anafysis in accardanc� with the
most re�ent DWQ palicy. If you answered "no," pro�ide a short narratir�e description_
4. Sewage Dispasal (DWQ Requirement)
4a. Cle�rly cfetail the ultimaie treatment methods and dispositian (non-discharge or discharge} of wastewater generated from
the praposed projeci, or a�ailable capacity of the subject faeility.
N/A
Page 9 of 10
PCN Form — Version 1.3 December 10, 2008 Versian

5. Endartgered Species and Designated GriEical Habitat {Corps Requirement)
5a_ Will this project occur in or near an area with federaffy protected species ar Yes ❑ No
habitat? �
5b. Have yau checiced with the U5FW5 ennceming Endangered Species Ac# � Yes � No
impacts?
❑ Rafeigh
5c. If yes, indicate the IJSFWS Field OfFice you h2ve contacted.
❑ Ashev�lle
5d. What data sources did yau use to determine v+►hether yaur site would impac# �ndangered Species or Designated Critical
Habitat?
NHP, GIS and visuai observation. NLEB habitat present but we are nat near a red HUC and will not be clearing #rees_
6. Essential Fish Habitat (Corps Requirementj
Ba. Will this project occur in or near an area designated as essential fish habitat? ❑ Yes � No
6b. Wfi�at data sources dFd you use to determin� whekher your site would impact Essential Fish Mabitat?
NOAA
7'. Historic or Prehistoric Cultural Resuurces (Corps Requirement}
7a. Will this project occur ih or near an area that the state, federal or tribaf
govemments ha�e designated as having historic or cultural preser�ation � Yes � No
status (e.g., Natiortal Historic Trust designation or proper#ies sigr�ificant in
Narth Carolina history and archaeolagy)?
7b. What data sources did you use to determine whether your site would impact historic ar archeofogical resources?
Proj�et is exempt. No National Register Praperties in the area.
8. Flood Zone Designation (Corps Requirementj
8a. Will this project occur in a�EMA-designated 100-year floadplain? � Yes ❑ No
8b. If yes, explain haw project meets FEMA requirements: Not changing grade, only raestablishing bank.
8c. What source(s) dd yo+� use to make the floodplain determination? rrcfloodmaps
J. Heath Slaughter G��Gd�+ 5/24117
ti
Applieant/Agent's Printed Name pplicantlAgenf' igr�ature Date
(Agent's s nature is �alid onEy 'rf an a rization letter from the appEicant
is rovided.)
Page 10 af 10
PCN Form — Version 1.3 December 10, 2008 Version

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