20180284 Ver 1_PCN Form Submission_20180226

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 2/26/2018 9:38:41 AM (Start Event)
Accept by Carpenter,Kristi 2/26/2018 4:09:14 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: March 1, 2018 5:00 PM
2/26/2018 9:39 AM

E-PCN Submittal
���
�lulslaa af Water Resources
Pre-Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
January 31, 2018 Ver 2.3
*
Please note: fields marked with a red asterisk below are required. You will not be ab/e to submit the form until all mandatory questions are ans�red.
Also, if at any point you wish to print a copy of the E-PCN, all you need to do is right-click on the document and you can print a copy of the form.
Below is a link to the online help file.
https://edocs. deq. nc.gov/WaterResources/0/edoc/624704/PCN%20Help%20File%202018-1-30. pdf
A. Processing Information
County(or Counties) where the project is located:*
Forsyth
Is this project a public transportation project? *(')
C�' Yes C' No
Is this a NCDOT Project?*
r Yes C' No
(NCDOT only) T.I.P. or state project number:
B-5771
WBS #
45727.1.1
(for NCDOT use only)
1a. Type(s) of approval sought from the Corps:*
rJ Section 404 Permit (wetlands, streams and waters, Clean Water Act)
r Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
1b. What type(s) of permit(s) do you wish to seek authorization?*
fJ Nationwide Permit (NWP)
r Regional General Permit (RGP)
Nationwide Permit (NWP) Number: 13 - Bank Stabilization
Nationwide Permit (NWP) Number: 33 - Temporary Construction
NWP Number Other:
List all MNnurrbers you are applying for not on the drop down list.
1c. Type(s) of approval sought from the DWR:*

check all that apply
ri 401 Water Quality Certification - Regular r 401 Water Quality Certification - E�ress
r Non-404 Jurisdictional General Permit r Riparian Buffer Authorization
*
1d. Is this notification solelyfor the record because written approval is not required?
For the record only for DWR 401 Certification:
For the record only for Corps Permit:
C•' Yes C' No
C' Yes �' No
1e. Is payment into a mitigation bank or in-lieu fee program proposed for mitigation of impacts?
If so, attach the acceptance letter from rritigation bank or in-lieu fee program
C' Yes �' No
1f. Is the project located in anyof NC's twentycoastal counties?*
C' Yes C•' No
1h. Is the project located in a designated trout watershed?*
f Yes C•' No
Link to trout information: http://w�nn�v.saw.usace.army.mil/Missions/Regulatory-Permit-PrograrrUAgency-Coordination/Trout.aspx

B. Applicant Information
B. Applicant Information
1a. Who is the Primary Contact?*
Amy Euliss
1b. Primary Contact Email:*
i [e-mail]
1c. PrimaryContact Phone:*
(xxx)xxx-xxxx
[phone]
1d. Who is applying for the permit?
fJ Owner r Applicant (other than owner) r Agent/Consultant
(Check all that apply)
2. Owner I nformation
2a. Name(s) on recorded deed:
NCDOT Division 9
2b. Deed book and page no.:
2c. Responsible party:
(for Corporations)
2d.Address
Street Address
375 Silas Creek Parkway
Address Line 2
Qty
Winston Salem
Fbstal / Zip Code
27127
2e. Telephone Number:
(xxx)xxx-xxxx
[phone]
2f. Fax Number:
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
State / Rovince / f�gion
NC
Country

C. Project Information and Prior Project History
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Replacement of Bridge no. 16 on SR 1611 (Main St)
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:*
Bethania
1d. Driving directions*
IF it is a new project and can not easily be found in a C�5 rrapping system Rease provide directions.
From Mvy 52, take NC 65 West to Main St in Bethania. Turn Right. Project crosses Muddy Creek.
2. Project Identification
i 2a. Property Identification Number:
(tax RN or parcel ID)
2b. Propertysize:
(in acres)
2c. Project Address
Street Address
Address Line 2
�Y
Fbstal / Zip Code
State / R-ovince / Region
Cauntry
2d. Site coordinates in decimal degrees
I Please collect site coordinates in decimal degrees. Use between 4-6 digits (unless you are using a survey-grade GPS device) after the decimal place as
appropriate, based on howthe location was determined. (For example, most mobile phones with GPS provide locational precision in decimal degrees to
map coordinates to 5 or 6 digits after the decimal place.)
Latitude: *
36.190681
ex:34208504
3. Surface Waters
Longitude:*
-80.336115
-77.796371
3a. Name of the nearest body of water to proposed project:*
Muddy Creek
3b. Water Resources Classification of nearest receiving water:*
Class C
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Yadkin-PeeDee

3c. What river basin(s) is your project located in?*
RiverBasin Lookup
4. Project Description
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:*
The existing area is rural and residential.
4b. Attach an 8 1/2 X 11 excerpt from the most recent version of the USGS topographic map indicating the location of the project site. (for
I DWR)
Gick the upload button or drag and drop files here to attach docurrent
Fle type rrust be pdF
4c. Attach an 8 1/2 X 11 excerpt from the most recent version of the published County NRCS Soil Survey map depicting the project site.
(for DWR)
Gick the upload button or drag and drop files here to attach docurrent
Fle type rrust be pdF
4d. List the total estimated acreage of all existing wetlands on the property:
0
4e. List the total estimated linear feet of all existing streams on the property:
(interrrittent and perennial)
120
4f. Explain the purpose of the proposed project:*
The project involves replacing the existing bridge in the same location with an off-site detour.
4g. Describe the overall project in detail, including indirect imapacts and the type of equipment to be used:*
The project involves replacing the existing bridge in the same location with an off-site detour. Stream banks will be
permanently stabilized with rip rap at ditch outlets and under the structure. Temporary fill will be placed in no more
i than half of the stream for bent removal and placement of bank stabilization.
4h. Please upload project drawings for the proposed project.
Qick the upload button or drag and drop files here to attach docurrent
B-5771 _Permit Drawings_20170919. pdf 1.71 MB
Fle type rrust be pdf
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the propertyor proposed impact areas?*
C� Yes �' No �' Unknown
Comments:
A JD was not requested from the USACE. The only jurisidctional feautre
noted was the main crossing of Muddy Creek.
5b. If the Corps made a jurisdictional determination, what type of determination was made? *
C' Preliminary C' Approved C' Unknown �' WA
Corps AID Number:
6carrple: SAVw2017-99999
Sc. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Melissa Ruiz, PWS and Pam Ferral
Agency/Consultant Company: Stantec

Sc. If 5a is yes, who delineated the jurisdictional areas?
Othe r:
5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5d1. Jurisdictional determination upload
Qick the upload button or drag and drop files here to attach docurrent
Fle type rrust be FDF
6. Project History
6a. Have permits or certifications been requested or obtained for this project (including all prior phases) in the past?*
C' Yes C' No c' Unknown
7. Future Project Plans
7a. Is this a phased project?*
C' Yes C•' No
Are any other NWP(s), regional general permit(s), or individual permits(s) used, or intended to be used, to authorize any part of the
proposed project or related activity? This includes other separate and distant crossing for linear projects that require Department of the
Army authorization but don't require pre-construction notification.

D. Proposed Impacts Inventory
D. Proposed I m pacts I nventory
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
� Wetlands �7 Streams-tributaries r Buffers
r Open Waters r Pond Construction
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
I impacted.
3a. Site #- Reason for 3b.lmpact
� impact* type*
1 P
Nl�p label (e.g. Finad Qossing 1) F2rrranent (Pj or
Terrporary (�
1 T
fv�ip label (e.g. Fd�ad Qossing 1) F2rrraner�t (Fj or
Terrporary (�
3c. Type of impact* 3d. Stream name *
Bank Stabilization Muddy Creek
Fill MuddyCreek
3e. Stream
Type *
Perennial
F2rennial (F�Z) or
interrrittent (If�
Perennial
F2rennial (FH�) or
interrrittent (If�
"* All Perennial or Intermittent streams must be verified by DWR or delegated local government.
3i. Total jurisdictional ditch impact in square feet:
0
3i. Total permanent stream impacts:
73
3i. Total temporarystream impacts:
37
3i. Total stream and tributary impacts:
110
3j. Comments:
Temporary fill impacts are to place fill in the stream to isolate the work area during both bank stabilization
placement and removal of an ewsting bent.
3f. Type of
Jurisdiction *
Corps
Corps
3g. Stream 3h. Impact
width* length*
30 73
Average (feet) Qinear feet)
30 37
Average(feet) pinearfeet)

E. Impact Justification and Mitigation
E. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:*
The bridge will be replaced in place with a new bridge and an off-site detour reducing impacts to Muddy Creek and
I the surrounding floodplain and National Register Historic district.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
Best management practices for Bridge Demolition and Sediment and Erosion Control will be implemented during
construction.
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?
C' Yes C•' No
2b. If this project DOES NOT require Compensatory Mitigation, explain why:
I Impacts don't involve a loss of water so mitigation is not being proposed.
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
"* Recent changes to the stormwater rules have required updates to this section .'�"
1. Diffuse Flow Plan
1a. Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian Buffer Protection
Rules?
C' Yes C•' No
For a list of options to meet the diffuse flow requirements, click here.
If no, explain why:
� No Riparian buffers in the Yadkin watershed.
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?*
�' Yes C' No

G. Supplementary Information
G. Supplementary Information
1. Environmental Documentation
1a. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state) land?*
C�' Yes C' No
1b. 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 PolicyAct (NEPA/SEPA)?*
C' Yes �' No
Comments:*
SEPA doesn't require preparation of an environmental document. Instead, a state Minimum Criteria Checklist has
been prepared.
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), or
DWR Surface Water or Wetland Standards or Riparian Buffer Rules (15A NCAC 2B .0200)? *
f Yes r No
2b. Is this an after-the-fact permit application?*
C' Yes �' No
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 downstream water qualit�i?*
C' Yes �' No
3b. If you answered "no," provide a short narrative description.
Replacing ebsting bridge in place
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project? *
C' Yes C' No �' f�UA
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or habitat?*
r Yes �' No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
C' Yes C•' No
5d. Is another Federal agency involved?*
C' Yes �' No
5e. Is this a DOT project located within Division's 1-8?*
C' Yes �' No
5f. Will you cut anytrees in order to conduct the work in waters of the U.S.?*
C� Yes C' No
C' Unknown

Sg. Does this project involve bridge maintenance or removal?*
C•' Yes C' No
5g(1). 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 can be found in the NLEB SLOPES, Appendix F, pages 3-7.
C� Yes C' No
Link to the NLEB SLOPES document: http://sav�reg.usace.army.mil/NLEB/1-30-17-signed_NLEBSLOPES&apps.pdf
If you answered "Yes" to 5g(1), did you discover any signs of bat use?*
C' Yes C•' No C' 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)?**
C' Yes �' No
5i. Does this project involve (1) blasting, and/or (2) other percussive activities that will be conducted by machines, such as jackhammers,
mechanized pile drivers, etc.?*
C� Yes C' No
If yes, please provide details to include type of percussive activity, purpose, duration, and specific location of this activity on the
prope rty.
C7ick the upload button or drag and drop files here to attach docurrent
Fle rrust be FDF
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
i NC Natural Heritage online database
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
C' Yes �' No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
NC Natural Heritage online database
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 properties significant in North Carolina historyand archaeology)?*
�' Yes �' No
i 7b. What data sources did you use to determine whether your site would impact historic or archeological resources? *
NCDOT Cultural Resources staff consulted with SHPO regarding the Bethania Historic District. See attached
documentation for both Historic Architecture (no adverse effect) and archeology (no sites present of affected).
Commitments including the 2 bar metal rail at appropriate bike height and plain concrete treatment to the parapet
wall have been incorporated to the design.
7c. Historic or Prehistoric Information Upload
aick the upload button or drag and drop files here to attach docurrent
16-03-0033_EffectsSigned.pdf 4.06M6
B-5771 Forsyth No NRHPArchaeological Sites Present Form.pdf 4.45MB
Fle rrust be FDF
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?*
r Yes C' No
8b. If yes, explain how project meets FEMA requirements:
MOA Type I
8c. What source(s) did you use to make the floodplain determination?*
NC Onemap
i Miscellaneous
Miscellaneous attachments not previously requested.
C7ick the upload button or drag and drop files here to attach docurrent
Br 16 SR 1611 Forsyth cover letter.pdf 227.4K6
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Signature Page
Signature
rJ By checking the box and signing below, I certify that:
■ I have given true, accurate, and complete information on this form;
■ I agree that submission of this PCN form is a"transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic
Transactions AcY');
■ I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic
Transactions AcY');
■ I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature; AND
. I intend to electronically sign and submit the PCN form.
Full Name:*
Amy Euliss
Signature
r��f j Url./r. cttl

Initial Review
Is this project a public transportation project? *(?)
C� Yes C' No
Change only if needed.
Has this project met the requirements for acceptance in to the review process?*
C� Yes
C' No
BIMS # Assigned*
20180284
Version#*
1
Reviewing Office*
Winston-Salem Regional Office - [phone]
Select Project Reviewer*
I Dave Wanucha:eads\djwanucha
Is a payment required for this project?*
C' No payment required
�' Fee received
C' Fee needed - send electronic notification