20170732 Ver 3_SAW-2009-01193 (signed GP31 verification) mod 2 404_20200422

PERMIT MODIFICATION (5/16/2018)
U.S. ARMY CORPS OF ENGINEERS
WILMINGTON DISTRICT
Action Id. SAW-2009-01193 County: Forsyth U.S.G.S. Quad: Winston-Salem West
GENERAL PERMIT (REGIONAL AND NATIONWIDE) VERIFICATION
Permittee: North Carolina Department of Transportation
Philip Harris III
Address: 1598 Mail Service Center
Raleigh, NC, 27699
Telephone Number: 919-707-6151
Size (acres) Nearest Town Winston-Salem
Nearest Waterway Peters Creek River Basin Upper Pee Dee
USGS HUC 03040101 Coordinates Latitude: 36.0896049496859
Longitude:-80.2574221558319
Location description: The project site is an existing interchange located west of Fourth St. on US 421/I-40 Business in the City
of Winston-Salem, Forsyth County, North Carolina. Aquatic features on site drain to Peters Creek in the Yadkin River basin.
Description of projects area and activity: This permit verification allows for 562 linear feet of permanent, and 226 linear feet of
temporary stream channel impacts associated with interchange improvements. Mitigation is required for this proposal. This
permit supersedes the previous verification issued on February 16, 2018.
Applicable Law: ® Section 404 (Clean Water Act, 33 USC 1344)
❑ Sections 10 (Rivers and Harbors Act, 33 USC 403)
Authorization: Regional General Permit Number or Nationwide Permit Number: GP 198200031 NCDOT Bridges, Widening
Proiects. (Authorized 2015)
SEE ATTACHED RGP or NWP GENERAL, REGIONAL AND SPECIAL CONDITIONS
Your work is authorized by the above referenced permit provided it is accomplished in strict accordance with the attached
conditions and your submitted application and attached information dated 06/13/2017, and 01/26/2018. Any violation of the
attached conditions or deviation from your submitted plans may subject the permittee to a stop work order, a restoration
order, a Class I administrative penalty, and/or appropriate legal action.
This verification will remain valid until the expiration date identified below unless the nationwide authorization is modified,
suspended or revoked. If, prior to the expiration date identified below, the nationwide permit authorization is reissued and/or
modified, this verification will remain valid until the expiration date identified below, provided it complies with all requirements of
the modified nationwide permit. If the nationwide permit authorization expires or is suspended, revoked, or is modified, such that the
activity would no longer comply with the terms and conditions of the nationwide permit, activities which have commenced (i.e., are
under construction) or are under contract to commence in reliance upon the nationwide permit, will remain authorized provided the
activity is completed within twelve months of the date of the nationwide permit's expiration, modification or revocation, unless
discretionary authority has been exercised on a case -by -case basis to modify, suspend or revoke the authorization.
Activities subject to Section 404 (as indicated above) may also require an individual Section 401 Water Quality Certification. You
should contact the NC Division of Water Resources (telephone [phone]) to determine Section 401 requirements.
For activities occurring within the twenty coastal counties subject to regulation under the Coastal Area Management Act (LAMA),
prior to beginning work you must contact the N.C. Division of Coastal Management in Elizabeth City, NC, at [phone].
This Department of the Army verification does not relieve the permittee of the responsibility to obtain any other required Federal,
State or local approvals/permits.
If there are any questions regarding this verification, any of the conditions of the Permit, or the Corps of Engineers regulatory
program, please contact James Lastinger at [phone] or James.C.Lastinger(&usace.army.mil.
RODEN
REYNOLDS.BRYAN.KENNETH.1263385574
Corps Regulatory Official: ""'°"'° Date: April 16, 2018

SAW-2009-01193
Expiration Date of Verification: 04/30/2020
The Wilmington District is committed to providing the highest level of support to the public. To help us ensure we
continue to do so, please complete our Customer Satisfaction Survey, located online at
http://corpsmgpu.usace.g,M.mil/cm_apex/f1p=136:4:0.
Copy furnished:
Agent: North Carolina Department of Transportation
Attn: Colin Mellor
Address: PDEA, Natural Environment Unit
1598 Mail Service Center
Raleigh, NC, 27699-1598
Telephone Number:

SAW-2009-01193
SPECIAL CONDITIONS
1. In order to compensate for impacts associated with this permit, mitigation shall be provided in
accordance with the provisions outlined on the most recent version of the attached Compensatory
Mitigation Responsibility Transfer Form. The requirements of this form, including any special
conditions listed on this form, are hereby incorporated as special conditions of this permit
authorization.
2. The Permittee shall fully implement the Project Commitments between the Permittee and the
North Carolina State Historic Preservation Officer, which is incorporated herein as Exhibit A.

Action ID Number: SAW-2009-01193 County: Forsyth
Permittee: North Carolina Department of Transportation
Philip Harris III
Project Name: NCDOT I-40Bus / US 421 / US 158 upgrade TIP U-2827B
Date Verification Issued: April 16, 2018
Project Manager: James Lastinger
Upon completion of the activity authorized by this permit and any mitigation required by the permit,
sign this certification and return it to the following address:
US ARMY CORPS OF ENGINEERS
WILMINGTON DISTRICT
Raleigh Regulatory Field Office
Attn: James Lastinger, Regulatory Project Manager
3331 Heritage Trade Dr., suite 105
Wake Forest, NC 27587
Please note that your permitted activity is subject to a compliance inspection by a U. S. Army Corps of
Engineers representative. Failure to comply with any terms or conditions of this authorization may
result in the Corps suspending, modifying or revoking the authorization and/or issuing a Class I
administrative penalty, or initiating other appropriate legal action.
I hereby certify that the work authorized by the above referenced permit has been completed in
accordance with the terms and condition of the said permit, and required mitigation was completed in
accordance with the permit conditions.
Signature of Permittee
Date

IL NOTIFICATION OF ADMINISTRATIVE APPEAL OPTIONS AND PROCESS AND
REQUEST FOR APPEAL
Applicant: North Carolina Department of
Transportation
Philip Harris III
File Number: SAW-2009-01193
Date: February 16, 2018
Attached is:
See Section below
❑
INITIAL PROFFERED PERMIT Standard Permit or Letter ofpermission)
A
❑
PROFFERED PERMIT Standard Permit or Letter ofpermission)
B
❑
PERMIT DENIAL
C
❑
APPROVED JURISDICTIONAL DETERMINATION
D
❑
PRELIMINARY JURISDICTIONAL DETERMINATION
E
SECTION I - The following identifies your rights and options regarding an administrative appeal of the above decision.
Additional information may be found at htip://www.usace.army.mil/Missions/CivilWorks/Re ug latoryProgramandPermits.aspx
or Corns regulations at 33 CFR Part 331.
A: INITIAL PROFFERED PERMIT: You may accept or object to the permit.
• ACCEPT: If you received a Standard Permit, you may sign the permit document and return it to the district engineer for final
authorization. If you received a Letter of Permission (LOP), you may accept the LOP and your work is authorized. Your
signature on the Standard Permit or acceptance of the LOP means that you accept the permit in its entirety, and waive all
rights to appeal the permit, including its terms and conditions, and approved jurisdictional determinations associated with the
permit.
OBJECT: If you object to the permit (Standard or LOP) because of certain terms and conditions therein, you may request
that the permit be modified accordingly. You must complete Section II of this form and return the form to the district
engineer. Your objections must be received by the district engineer within 60 days of the date of this notice, or you will
forfeit your right to appeal the permit in the future. Upon receipt of your letter, the district engineer will evaluate your
objections and may: (a) modify the permit to address all of your concerns, (b) modify the permit to address some of your
objections, or (c) not modify the permit having determined that the permit should be issued as previously written. After
evaluating your objections, the district engineer will send you a proffered permit for your reconsideration, as indicated in
Section B below.
B: PROFFERED PERMIT: You may accept or appeal the permit
• ACCEPT: If you received a Standard Permit, you may sign the permit document and return it to the district engineer for final
authorization. If you received a Letter of Permission (LOP), you may accept the LOP and your work is authorized. Your
signature on the Standard Permit or acceptance of the LOP means that you accept the permit in its entirety, and waive all
rights to appeal the permit, including its terms and conditions, and approved jurisdictional determinations associated with the
permit.
APPEAL: If you choose to decline the proffered permit (Standard or LOP) because of certain terms and conditions therein,
you may appeal the declined permit under the Corps of Engineers Administrative Appeal Process by completing Section II of
this form and sending the form to the division engineer. This form must be received by the division engineer within 60 days
of the date of this notice.
C: PERMIT DENIAL: You may appeal the denial of a permit under the Corps of Engineers Administrative Appeal Process by
completing Section II of this form and sending the form to the division engineer. This form must be received by the division
engineer within 60 days of the date of this notice.

D: APPROVED JURISDICTIONAL DETERMINATION: You may accept or appeal the approved JD or provide new
information.
• ACCEPT: You do not need to notify the Corps to accept an approved JD. Failure to notify the Corps within 60 days of the
date of this notice, means that you accept the approved JD in its entirety, and waive all rights to appeal the approved JD.
• APPEAL: If you disagree with the approved JD, you may appeal the approved JD under the Corps of Engineers
Administrative Appeal Process by completing Section II of this form and sending the form to the district engineer. This form
must be received by the division engineer within 60 days of the date of this notice.
E: PRELIMINARY JURISDICTIONAL DETERMINATION: You do not need to respond to the Corps regarding the
preliminary JD. The Preliminary JD is not appealable. If you wish, you may request an approved JD (which may be appealed),
by contacting the Corps district for further instruction. Also you may provide new information for further consideration by the
Corps to reevaluate the JD.
SECTION II - RE PEAL or OBJECTIONS TO AN INITIAL PROFFERED PERMIT
REASONS FOR APPEAL OR OBJECTIONS: (Describe your reasons for appealing the decision or your objections to an initial
proffered permit in clear concise statements. You may attach additional information to this form to clarify where your reasons or
objections are addressed in the administrative record.)
ADDITIONAL INFORMATION: The appeal is limited to a review of the administrative record, the Corps memorandum for the
record of the appeal conference or meeting, and any supplemental information that the review officer has determined is needed to
clarify the administrative record. Neither the appellant nor the Corps may add new information or analyses to the record.
However, you may provide additional information to clarify the location of information that is already in the administrative
record.
POINT OF CONTACT FOR QUESTIONS OR INFORMATION:
If you have questions regarding this decision and/or the
If you only have questions regarding the appeal process you may
appeal process you may contact:
also contact:
District Engineer, Wilmington Regulatory Division,
Mr. Jason Steele, Administrative Appeal Review Officer
Raleigh Regulatory Field Office
CESAD-PDO
Attn: James Lastinger, Regulatory Project Manager
U.S. Army Corps of Engineers, South Atlantic Division
3331 Heritage Trade Dr., suite 105
60 Forsyth Street, Room 1OM15
Wake Forest, NC 27587
Atlanta, Georgia 30303-8801
919-554-4884 ext 32
Phone: [phone]
RIGHT OF ENTRY: Your signature below grants the right of entry to Corps of Engineers personnel, and any government
consultants, to conduct investigations of the project site during the course of the appeal process. You will be provided a 15 day
notice of any site investigation, and will have the opportuni to participate in all site investi ations.
Date:
Telephone number:
Signature of appellant or agent.
For appeals on Initial Proffered Permits send this form to:
District Engineer, Wilmington Regulatory Division, Attn: James Lastinger, 69 Darlington Avenue, Wilmington, North
Carolina 28403
For Permit denials, Proffered Permits and Approved Jurisdictional Determinations send this form to:
Division Engineer, Commander, U.S. Army Engineer Division, South Atlantic, Attn: Mr. Jason Steele, Administrative Appeal
Officer, CESAD-PDO, 60 Forsyth Street, Room 1OM15, Atlanta, Georgia 30303-8801
Phone: [phone]

Compensatory Mitigation Responsibility Transfer Form
Permittee: North Carolina Department of Transportation
Project Name: U-2827B
Action ID: SAW-2009-001193
County: Forsyth
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: 03040101, Yadkin River Basin
Stream Impacts (linear feet)
Wetland Impacts (acres)
Warm
Cool
Cold
RiparianRiverine
Riparian Non-Riverine
Non -Riparian
Coastal
54
*If more than one mitigation sponsor will be used for the permit, only include impacts to be mitigated by this sponsor.
Compensatory Mitigation Requirements: 8-digit HUC and Basin: 03040101, Yadkin River Basin
Stream Mitigation (credits)
Wetland Mitigation (credits)
Warm
Cool
Cold
Riparian
Riparian Non -
Non -Riparian
Coastal
Riverine
Riverine
54
Mitigation Site Debited: NCDMS
(List the name of the bank to be debited. For umbrella banks, also list the specific site.
acceptance letter identifies a specific site, also list the specific site to be debited).
For NCDMS, list NCDMS. If the NCDMS
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 Sponsor 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 Name:
Name of Sponsor's Authorized Representative:
Signature of Sponsor's Authorized Representative Date of Signature

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 of 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 Sponsor 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 Sponsor, 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: 54 linear feet required under this re -verification. Additional mitigation has been secured
by applicant under the original verification. Total compensatory mitigation is 512 linear feet for the original verification (July
11, 2017), permit modification #1 (February 16, 2018), and permit modification #2 (May 16, 2018).
This form is not valid unless signed below by the USACE Project Manager and by the Mitigation Sponsor on Page 1. Once
signed, the Sponsor should provide copies of this form along with an updated bank ledger to:1) the Permittee, 2) the USACE
Project Manager at the address below, and 3) the Wilmington District Mitigation Office, Attn: Todd Tugwell, 11405 Falls
of Neuse Road, Wake Forest, NC27587 (email: todd. tugwell@usace. army. mil). Questions regarding this form or any of the
permit conditions may be directed to the USACE Project Manager below.
USACE Project Manager: James Lastinger
USACE Field Office: Raleigh Regulatory Office
US Army Corps of Engineers
3331 Heritage Trade Drive, Suite 105
Wake Forest, North Carolina 27587
Email: [e-mail]
RODEN Digitally signed by RODEN
REYNOLDS.BRYAN.KEN N ETH.1263385574
REYNOLDS.BRYAN.KENNETH.1263 DN:c=US,o=U.S.Government,ou=DoD,ou=PKI,ou=USA,
cn=RODEN REYNOLDS.BRYAN.KENNETH.1263385574
385574 Date: 2018.05.1610:4358-04'00' 05/ 16/2018
USACE Project Manager Signature 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://ribits.usace.army.mil

Exhibit A
U-2827B, Forsyth County
I-40 Business/US 421 Improvements
Historic Architectural Resources — No Adverse Effects with Conditions
West Fourth Street Historic District (FY3466 — DE). Alternatives 4. 1. All
construction easements will be temporary. 2. Replace and extend retaining wall along
Peter's Creek Parkway; apply brick or ashlar treatment to wall surface facing houses.
West Salem Historic District (FY3011 - NR). Alternatives 4. Create a T-
turnaround on Green Street.
Holly Avenue Historic District (FY2656 — NR).
Alternative 4. Marshall Street ramp remains in place. Retaining/noise wall to be single -
faced barrier with brick or ashlar treatment. At #116 S. Marshall Street (PIN: 5835-15-
4256) one existing driveway to be eliminated, one maintained and improved and North
Carolina State Historic Preservation Office to review finalized plan.
James Mitchell Rogers House (FY0098 — NR, LD). Alternative 4. Flatten curve of
ramp (move slightly north) and establish ramp as free -flow.
Conrad Starbuck House (FY1417 NR, LD). Alternative 4. Flatten curve of ramp
(move slightly north) and establish ramp as free -flow.
Henry F. Shaffner House (FY0901— SL, DE). Alternative 4. Ramp redesign to
require no right-of-way acquisition. Access to be preserved, all construction easements
temporary.
7 July 2017

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