20090390 Ver 1_Application_20090413

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Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Pre-Construction Notification (PCN) Form
A. Applicant Information
1. Processing
Ia. Type(s) of approval sought from the
Corps: X
Section 404 Permit El Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: 3 . or General Permit (GP) number:
1 c. Has the NWP or GP number been verified by the Corps? X Yes No
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 X Riparian Buffer Authorization
le. Is this notification solely for the record
because written' approval is not required? For the record only for DWQ 401
Certification:
X Yes No For the record only for Corps Permit:

? Yes X No
If. 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. ? Yes X No
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below. XYes ? No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ? Yes XNo
2. Project Information
2a. Name of project: SR 1711, Worthington Road Pipe Number 1
2b. County: Pitt,
2c. Nearest municipality / town: Winterville
2d. Subdivision name: N/A
2e. NCDOT only, T.I.P. or state
project no: 40466
3. Owner Information
3a. Name(s) on Recorded Deed:
3b. Deed Book and Page No.
3c. Responsible Party (for LLC if
applicable):
3d. Street address:
3e. 'City, state, zip:
t3f. Telephone no.:
I3g. Fax no.:
13h. Email address:
i
Page 1 of 11
PCN Fonn - Version 1.3 December 10, 2008 Version
4. Applicant Information (if different from owner)
4a. Applicant is: X Agent ? Other, specify:
4b. Name: Jay B. Johnson
4c. Business name
(f applicable): North Carolina Department of Transportation
4d. Street address: P.O. Box 1587
4e. 'City, state, zip: Greenville, NC 27835
4f. Telephone no.: 252-8304490
4g. Fax no.: 252-8304341
4h. Email address:
5. Agent/Consultant Information (if applicable)
5a. Name:
.5b. Business name
(f applicable):
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:
Page 2 of 11
B. Project Information and Prior Project Histor y
1. Property Identification
I a. Property identification no. (tax PIN or parcel ID): N/A

1b. Site coordinates (in decimal degrees): Latitude: N 35.529287 Degrees Longitude:
W 77.359378 Degrees
(DD.DDDDDD) . (-DD.DDDDDD)
1c. Property size: NIA acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
proposed project: Fork Swamp
2b. Water Quality Classification of nearest receiving water: C;Sw;NSW
2c. River basin: Neuse
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:
The Surrounding Area is Wooded and Agricultural With Single Family Homes
3b. List the total estimated acreage of all existing wetlands on the property:
N/A
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
NIA
3d. Explain the purpose of the proposed project:
Pipe to Pipe Replacement
3e. Describe the overall project in detail, including the type of equipment to be used:
Use Highway Construction Equipment to Replace the Existing 30" x 40' Pipes with a Proposed 36" x 50'
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?
Comments:
Yes X No ? Unknown
4b. If the Corps made the jurisdictional determination, what type
of determination was made?
? Preliminary[] Final
4c. If yes, who delineated the jurisdictional areas?
Name (if known): Agency/Consultant Company:
Other: NCDOT And NCDWQ
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5. Project History
5a. Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past? ? Yes X No ? Unknown
5b. If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
6a. Is this a phased project? ? Yes X No
6b. If yes, explain.
Page 3 of 11
PCN Form - Version 1.3 December 10, 2008 Version
C. Proposed Impacts Inventory
1. Impacts Summary
I a. Which sections were completed below for your project (check all that apply):
?Wetlands XStreams - tributaries XBuffers
? 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 of jurisdiction
number - Type of impact Type of wetland Forested (Corps - 404, 10 Area of impact
Permanent (P) or (if known) DWQ - non-404, other) (acres)
Temporary (T)
W1 ? P ? T 0 s 0
0
? No ? DWQ .
W2 ? P ? T ? Yes ? Corps
? No ? DWQ
W3 ? PEI T ? Yes ? Corps
? No ? DWQ
W4 ? PEI T ? Yes ? Corps
? No ? DWQ
W5 ? PEI T ? Yes ? Corps
? No ? DWQ
W6 ? P ? T ? Yes ? Corps
? No ? DWQ
2g. Total wetland impacts 0.0
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. 3g.
Stream impact Type of impact Stream name Perennial Type of jurisdiction Average Impact
number- (PER) or (Corps-404,10 stream length
Permanent (P) or intermittent DWQ - non4-04, width (linear
Temporary (T) (INT)? other) (feet) feet)
St X P ? T Pipe Placement U/T of Fork
Swamp X PER
? INT X Corps
XDWQ ?, 10'
S2 ? P ? T ? PER ? Corps
? INT ? DWQ
S3 ? POT ? PER ? Corps
? INT ? DWQ
S4 ? PEI T ? PER ? Corps
? INT ? DWQ
S5 ? P ? T ? PER ? Corps
? INT ? DWQ
S6 ? P ? T PER ? Corps
? INT ? DWQ
3h. Total stream and tributaryimpacts 10,
3i. Comments:
Page 4 of 11
PCN Form - Version 1,3 December 10, 2008 Version
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 individual) list all open water impacts below.
4a.
Open water
impact number-
Permanent (P) or
Temporary 4b.
Name of waterbody
(if applicable) 4c.

Type of impact 4d.

Waterbody type 4e.

Area of impact (acres)
01 ?P?T
02 ?P?T
03 ?P?T
04-?P?T
4f. Total open water impacts 0.0
4g. Comments:
5. Pond or Lake Construction
If and or lake construction proposed, then.complete the chart below.
5a.

Pond ID 5b.

Proposed use or purpose 5c.
Wetland Impacts (acres) 5d.
Stream Impacts (feet) 5e.
Upland
(acres)
number of pond
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1
P2
5f. Total 0.0 0.0 0.0
5g. Comments:
5h. Is a dam high hazard permit required?
? Yes X No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
Page 5 of 11
j
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 impacts require mitigation, then you MUST fill out Section D of this form.
6a. X Neuse ? Tar-Pamlico ? Other:
Project is in which protected basin? ? Catawba ? Randleman
6b. 6c. 6d. 6e. 6f. 6g.
Buffer impact
number- Reason Buffer Zone t impact Zone 2 impact
Permanent (P) or for Stream name mitigation (square feet) (square feet)
Temporary impact required?

Bt ? P ? T Pipe
Replac
Tributary of Fork Swamp ? Yes
X No .
600 Sq. Ft.
400,Sq. Ft
ement
B2 ?P?T ?Yes
? No
B3 ?P?T ?Yes
? No
6h. Total buffer impacts 600 Sq. Ft. 400 Sq. Ft
6i. Comments:
Page 6 of 11 .
s
i1
D. Impact Justification and Mitigation
7. Avoidance and Minimization
la. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
All Construction Equipment Will Be Operated Within The Footprint of the Existing Roadway So As To Prevent
The Disturbance Of Any Vegetated Areas Or Jurisdictional Waters At The Site
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? ? Yes XNo
2b. If yes, mitigation is required by (check all that apply): ? DWQ ? Corps

2c. If yes, which mitigation option will be used for this
project? ? Mitigartion bank
? Payment to in-lieu fee program

? Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank N/A
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter) Type Quantity
3c. Comments:
4. Complete if Making a Payment to In4ieu Fee Program N/A
4a. Approval letter from in-lieu fee program is attached. ? Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mfigation, stream temperature: ?"warm ? cool ?cold
4d. Buffer mitigation requested (DWQ only): square feet
4e. Riparian wetland mitigation requested: acres
4f. Non-riparian wetland mitigation requested: acres
49. Coastal (tidal) wetland mitigation requested: acres
4h. Comments:
5. Complete if Using a Perrnittee Responsible Mitigation Plan NIA
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 7 of 11
PCN,F.oirn - Version 1.3 December 10, 2008 Version
6. Buffer Mitigation (State Regulated Riparian Buffer Rules) - required by DWQ N/A
6a. Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation? ? Yes X No
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 6c.
Reason for impact 6d..
Total impact
(square feet)
Multiplier 6e.
Required mitigation
(square feet)
Zone 1 3 (2 for Catawba)
Zone 2 1.5
6f. Total buffer mitigation required:
6g. 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).
6h. Comments:
i
Page 8 of 11
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
I a. Does the project include or is it adjacent to protected riparian buffers identified X Yes ? No
within one of the NC Riparian Buffer Protection Rules?
1b. If yes, then is a diffuse flow plan included? If no, explain why.
Comments: Diffuse Flow Through Vegetated Uplands Before Entering X Yes ? No
Wetlands Will Be Used For This Pipe Replacement
2. Stor mwater Management Plan

2a . What is the overall percent imperviousness of this project? 0%
2b . Does this project require a Stormwater Management Plan? Yes X NO
2c. If this,project DOES NOT require a Stormwater Management Plan, explain why:
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
? Certified Local Government
2e. Who will be responsible for the review of the stormwater Management Plan? ? DWQ Stormwater Program
? DWQ 401 Unit
3. Certified Local Government Stormwater Review NIA
3a. In which local government's jurisdiction is this project?
? Phase II
? NSW
3b. Which of the following locally-implemented stormwater management programs ? USMP
apply (check all that apply): ? Water Supply Watershed
? Other:
3c. Has the approved Stormwater Management Plan with proof of approval been ? Yes ? No
attached?
4. DWQ Stormwater Program Review
Coastal counties
? HQW
4a . Which of the following state-implemented stormwater management programs apply ? ORW
(check all that apply): ? Session Law 2006-246
X Other: NPDES Permit
4b . Has the approved Stormwater Management Plan with proof of approval been
? Yes XNo
attached?
5. DWQ 401 Unit Stormwater Review WA

5a . Does the Stormwater Management Plan meet the appropriate requirements? XYes ? No
5b. Have all of the 401 Unit submittal requirements been met? X Yes ? No
Page 9 of 11
P,CN Form -;Version 1.3 Deoember,10, 2068 Version

F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
la. Does the project involve an expenditure of public (federal/state/local) funds or the [9 Yes ? No
use of public (federal/state) land?
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 ? 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 BufferRules (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):
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 descripf on.
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. '
Page 10 of 1y1 1
PGN Form - Version •1,3 December 10, 2008 Version

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or ? Yes ® No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act ? Yes ® No
impacts?
? Raleigh
5c. If yes, indicate the USFWS Field Office you have contacted.
'? Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
NHP GIS Data Layer and Onsite Observation
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?
North Carolina Wildlife Resources Commission
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?
North Carolina State Historic Preservation Office
8. Flood Zone Designation (Corps Requirement)
8a..Will this project occur in a FEMA-designated 100-year floodplain? ® Yes ? No
Bb. If yes, explain how project meets FEMA requirements: The Pipe Replacement Will Not Raise the Elevation Within The
Floodplain
8c. What source(s) did you use to make the floodplain determination? NC Flood Map
Jay B. Johnson
xrtX1A V,44A? March 13, 2009
Applicant/Agent's Printed Name Appli U ent' ignature Date
(Agent's signature is vali ly i a cation letter from the applicant
is provided.)
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