20191637 Ver 2_PCN-Revised_20200908

Pre-Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
April 11, 2020 Ver 3.1
Please note: fields marked with a red asterisk * below are required. You will not be able to submit the form until all mandatory questions are answered.
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
County (or Countie s) where the proje ct is locate d:*
Is this a NCDM S Proje ct *
Is this project a public transportation project?*
1a. Type (s) of approv al sought from the Corps:*
1b. What type (s) of pe rmit(s) do you wish to se e k authorization?*
This form may be used to initiate the standard/individual permit process with the Corps. Please contact your Corps representative concerning submittals for standard permits. All required items that
are not provided in the E-PCN can be added to the miscellaneous upload area located at the bottom of this form.
1c. Has the NWP or GP numbe r be e n v e rifie d by the Corps?*
Nationwide Pe rmit (NWP) Numbe r:
NWP Numbe rs (for multiple NWPS):
1d. Type (s) of approv al sought from the DWR:*
1e . Is this notification sole ly for the re cord be cause writte n approv al is not re quire d?
*
For the re cord only for DWR 401 Ce rtification:
For the re cord only for Corps Pe rmit:
1f. Is this an afte r-the -fact pe rmit application?*
1g. Is payme nt into a mitigation bank or in-lie u fe e program propose d for mitigation of impacts?
Acce ptance Le tte r Attachme nt
A. Processing Information
Wake
Yes No
Click Yes, only if NCDMS is the applicant or co-applicant.
Yes No
This is any publicly funded by municipal,state or federal funds road, rail, airport transportation project.
Section 404 Permit (wetlands, streams and waters, Clean Water Act)
Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
Nationwide Permit (NWP)
Regional General Permit (RGP)
Standard (IP)
Yes No
29 - Residential Developments
List all NW numbers you are applying for not on the drop dow n list.
check all that apply
401 Water Quality Certification - Regular 401 Water Quality Certification - Express
Non-404 Jurisdictional General Permit Riparian Buffer Authorization
Individual Permit
Yes No
Yes No
Yes No
If so, attach the acceptance letter from mitigation bank or in-lieu fee program.
Yes No
1h. Is the proje ct locate d in any of NC's twe nty coastal countie s?*
1j. Is the proje ct locate d in a de signate d trout wate rshe d?*
Link to trout information: http://www.saw.usace.army.mil/Missions/Regulatory-Permit-Program/Agency-Coordination/Trout.aspx
1a. Who is the Primary Contact?*
1b. Primary Contact Email:*
1c. Primary Contact Phone :*
1d. Who is applying for the pe rmit?*
1e . Is the re an Age nt/Consultant for this proje ct?*
2. Owner Information
Click the upload button or drag and drop files here to attach document
FILE TYPE MUST BE PDF
Yes No
Yes No
B. Applicant Information
Josh Swindell
[e-mail]
(xxx)xxx-xxxx
[phone]
Owner Applicant (other than owner)
(Check all that apply)
Yes No
2a. Name (s) on re corde d de e d:*
2b. De e d book and page no.:
2c. Re sponsible party:
2d. Addre ss *
2e . Te le phone Numbe r:*
2f. Fax Numbe r:
2g. Email Addre ss:*
J Dallas Herndon Heirs
Book: 08-E; Page: 3122
(for Corporations)
City
Apex
State / Province / Region
NC
Postal / Zip Code
27502
Country
United States
Street Address
1010 N Salem Street
Address Line 2
(xxx)xxx-xxxx
[phone]
(xxx)xxx-xxxx
[e-mail]
2a. Name (s) on re corde d de e d:*
2b. De e d book and page no.:
2c. Re sponsible party:
2d. Addre ss *
2e . Te le phone Numbe r:*
Charles and Annette Herndon
Book: 6437; Page: 156
(for Corporations)
City
Mount Olive
State / Province / Region
NC
Postal / Zip Code
28365
Country
United States
Street Address
531 Country Club Road
Address Line 2
(xxx)xxx-xxxx
[phone]
3. Applicant Information (if different from owner)
4. Agent/Consultant (if applicable)
2f. Fax Numbe r:
2g. Email Addre ss:*
(xxx)xxx-xxxx
[e-mail]
2a. Name (s) on re corde d de e d:*
2b. De e d book and page no.:
2c. Re sponsible party:
2d. Addre ss *
2e . Te le phone Numbe r:*
2f. Fax Numbe r:
2g. Email Addre ss:*
Charleston Village Homeowners Association
Book: 8767; Page: 2027
(for Corporations)
City
Apex
State / Province / Region
NC
Postal / Zip Code
27502
Country
United States
Street Address
315 S. Salem Street
Address Line 2
(xxx)xxx-xxxx
[phone]
(xxx)xxx-xxxx
[e-mail]
3a. Name :*
3b. Business Name :
3c. Addre ss *
3d. Te le phone Numbe r:*
3e . Fax Numbe r:
3f. Email Addre ss:*
Josh Swindell
(if applicable)
Envision Homes
City
Raleigh
State / Province / Region
NC
Postal / Zip Code
27609
Country
United States
Street Address
4441 Six Forks Road, Suite 106-117
Address Line 2
[phone]
(xxx)xxx-xxxx (xxx)xxx-xxxx
[e-mail]
4a. Name :*
4b. Business Name :
4c. Addre ss *
Scott Mitchell
(if applicable)
Mitchell Environmental, PA
City
Fuquay-Varina
State / Province / Region
NC
Postal / Zip Code
27526
Country
United States
Street Address
1501 Lakestone Village Lane, Suite 205
Address Line 2
1a. Name of proje ct:*
1b. Subdivision name :
1c. Ne are st municipality / town:*
2a. Prope rty Identification Numbe r:2b. Prope rty size :
2c. Proje ct Addre ss
2d. Site coordinate s in de cimal de gre e s
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 how the 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 :*Longitude :*
3. Surface Waters
3a. Name of the ne are st body of wate r to propose d proje ct:*
3b. Wate r Re source s Classification of ne are st re ce iv ing wate r:*
Surface Water Lookup
3c. What riv e r basin(s) is your proje ct locate d in?*
3d. Ple ase prov ide the 12-digit HUC in which the proje ct is locate d.*
River Basin Lookup
4. Project Description and History
4a. De scribe the e xisting conditions on the site and the ge ne ral land use in the v icinity of the proje ct at the time of this application:*
4b. Hav e Corps pe rmits or DWR ce rtifications be e n obtained for this project (including all prior phase s) in the past?*
4d. Te le phone Numbe r:*
4e . Fax Numbe r:
4f. Email Addre ss:*
Age nt Authorization Le tter *
[phone]
(xxx)xxx-xxxx (xxx)xxx-xxxx
[e-mail]
Please provide the Agent Authorization Letter if you are submitting this document.
Holt Road agent authorization signed.pdf 62.98KB
FILE TYPE MUST BE PDF
C. Project I nformation and Prior Project History
1. Project Information
Tullamore Subdivision
(if appropriate)
Tullamore
Apex
2. Project Identification
(tax PIN or parcel ID)
0733839147; 0733835369; 0733828561
(in acres)
13.11
City
Apex
State / Province / Region
NC
Postal / Zip Code
27502
Country
United States
Street Address
1745 Holt Road
Address Line 2
35.764043
ex: 34.208504
-78.868958
-77.796371
Beaver Creek
WS-IV; NSW
Cape Fear
030300020609
The existing conditions on the site consists of open field and wooded areas. The general land use in the vicinity is mostly residential.
4d. Attach an 8 1/2 X 11 e xce rpt from the most re ce nt v e rsion of the USGS topographic map indicating the location of the proje ct site . (for DWR)
4e . Attach an 8 1/2 X 11 e xce rpt from the most re ce nt v e rsion of the publishe d County NRCS Soil Surv e y map de picting the proje ct site . (for DWR)
4f. List the total e stimate d acre age of all e xisting we tlands on the prope rty:
4g. List the total e stimate d line ar fe e t of all e xisting stre ams on the prope rty:
4h. Explain the purpose of the propose d proje ct:*
4i. De scribe the ov e rall proje ct in de tail, including indirect impacts and the type of e quipme nt to be use d:*
4j. Ple ase upload proje ct drawings for the propose d proje ct.
5. Jurisdictional Determinations
5a. Hav e the we tlands or streams be e n de line ate d on the prope rty or propose d impact are as?*
Comme nts:
5b. If the Corps made a jurisdictional de te rmination, what type of de te rmination was made ?*
Corps AID Numbe r:
5c. If 5a is ye s, who de line ate d the jurisdictional are as?
Name (if known):
Age ncy/Consultant Company:
Othe r:
5d. List the date s of the Corp jurisdiction de te rmination or State de te rmination if a de te rmination was made by the Corps or DWR.
5d1. Jurisdictional de te rmination upload
6. Future Project Plans
6a. Is this a phase d proje ct?*
Are any othe r NWP(s), re gional ge ne ral pe rmit(s), or indiv idual pe rmits(s) use d, or intende d to be use d, to authorize any part of the propose d project or re lated activ ity? This
include s othe r se parate and distant crossing for line ar proje cts that re quire De partme nt of the Army authorization but don’t re quire pre -construction notification.
1. Impacts Summary
1a. Whe re are the impacts associate d with your proje ct? (che ck all that apply):
Yes No Unknown
Click the upload button or drag and drop files here to attach document
Holt Road Assemblage USGS.pdf 336.11KB
File type must be pdf
Click the upload button or drag and drop files here to attach document
Soil Survey Map.pdf 1.17MB
File type must be pdf
0.9731
(intermittent and perennial)
201
The purpose of the project is to develop the property into a residential subdivision.
Equipment to be used is that typical of subdivision and roadway installation including excavators, bull dozers, dump trucks, etc.
Click the upload button or drag and drop files here to attach document
2020-05-15 Tullamore CD's 2nd Submittal.pdf 43.05MB
File type must be pdf
Yes No Unknown
Preliminary Approved Not Verified Unknown N/A
Example: SAW-2017-99999
Corps AID number unknown
Mitchell Environmental, PA
Corps: October 1, 2018
DWR: December 2, 2019 (DWR Project # 20191637)
Click the upload button or drag and drop files here to attach document
1745HoltRoad_Apex_WakeCo_Stream Appeal 120919.pdf 2.97MB
File type must be PDF
Yes No
D. Proposed Impacts Inventory
Wetlands Streams-tributaries Buffers
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.
"W." will be use d in the table be low to re pre se nt the word "we tland".
2a. Site #*(?)2a1 Re ason *(?)2b. Impact type *(?)2c. Type of W.*2d. W. name *2e . Fore ste d *2f. Type of
Jurisdicition *(?)
2g. Impact
are a *
2g. Total Te mporary We tland Impact
2g. Total Pe rmane nt We tland Impact
2g. Total We tland Impact
2h. Comme nts:
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.
"S." will be used in the table below to represent the word "stream".
3a. Reason for impact *(?)3b.Impact type *3c. Type of impact *3d. S. name *3e . Stre am Type *
(?)
3f. Type of
Jurisdiction *
3g. S. width *3h. Impact
le ngth *
S1
** All Perennial or Intermittent streams must be verified by DWR or delegated local government.
3i. Total jurisdictional ditch impact in square fe e t:
3i. Total pe rmane nt stre am impacts:
3i. Total te mporary stre am impacts:
3i. Total stre am and ditch impacts:
3j. Comme nts:
6. Buffer Impacts (for DWR)
If project will impact a protected riparian buffer, then complete the chart below. Individually list all buffer impacts below.
6a. Proje ct is in which prote ct basin(s)?*
6b. Impact Type *(?)6c. Pe r or Te mp *(?)6d. Stre am name *6e . Buffe r mitigation re quired?*6f. Zone 1 impact *6g. Zone 2 impact *
6h. Total buffer impacts:
1 Road and Lot Fill P Headwater Forest A Yes Both 0.036
(acres)
2 Road Fill P Headwater Forest A No Both 0.086
(acres)
0.000
0.122
0.122
Rip Rap Dissipator Permanent Rip Rap Fill A Perennial Both 4
Average (feet)
10
(linear feet)
0
10
0
10
Check all that apply.
Neuse Tar-Pamlico
Catawba Randleman
Goose Creek Jordan Lake
Other Cape Fear
Grading/Stormwater P A No 1,135
(square feet)
2,777
(square feet)
Sewer Crossing P A No 3,395
(square feet)
1,607
(square feet)
Pine Tree Removal T A No 0
(square feet)
435
(square feet)
Wetland
Zone 1 Zone 2
Total Te mporary impacts:
Zone 1 Zone 2
Total Pe rmane nt impacts:
Zone 1 Zone 2
Total combine d buffe r impacts:
6i. Comme nts:
Supporting Docume ntation - i.e . Impact M aps, Plan She e t, e tc.
1. Avoidance and Minimization
1a. Spe cifically de scribe me asure s take n to av oid or minimize the propose d impacts in de signing the proje ct:*
1b. Spe cifically de scribe me asure s take n to av oid or minimize the propose d impacts through construction te chnique s:*
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Doe s the proje ct re quire Compe nsatory M itigation for impacts to Wate rs of the U.S. or Wate rs of the State ?
2c. If ye s, mitigation is re quire d by (che ck all that apply):
2d. If ye s, which mitigation option(s) will be use d for this proje ct?
3. Complete if Using a Mitigation Bank
3a. Name of M itigation Bank:
3b. Cre dits Purchase d/Requeste d (attach re ce ipt and le tte r)
Type :Quantity:
Attach Re ce ipt and/or le tter
3c. Comme nts
NC Stream Temperature Classification Maps can be found under the Mitigation Concepts tab on the Wilmington District's RIBITS website.
*** Recent changes to the stormwater rules have required updates to this section .***
1. Diffuse Flow Plan
1a. Doe s the proje ct include or is it adjace nt to prote cte d riparian buffers ide ntifie d within one of the NC Riparian Buffe r Prote ction Rule s?
1b. All buffer impacts and high ground impacts re quire diffuse flow or othe r form of stormwate r treatme nt. If the proje ct is subje ct to a state imple me nte d riparian buffe r prote ction
program, include a plan that fully docume nts how diffuse flow will be maintaine d.
All Stormwate r Control M e asure s (SCM )s must be de signe d in accordance with the NC Stormwate r De sign M anual. Associate d supple me nt forms and othe r docume ntation shall be
prov ide d.
0.00 435.00
4,530.00 4,384.00
4,530.00 4,819.00
Click the upload button or drag and drop files here to attach document
C-04 DEMOLITION PLAN.PDF 2.86MB
File must be PDF
E. Impact Justification and Mitigation
The road length was shortened from original design to minimize fill and grading. Lot lines were adjusted to minimize impacts as well, including the
reduction of total proposed lots.
Silt and tree protection fencing will be installed to ensure construction and impacts remain inside approved areas.
Yes No
DWR Corps
Mitigation bank Payment to in-lieu fee
program
Permittee Responsible
Mitigation
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FILE TYPE MUST BE PDF
SOA will be provided as soon as received from mitigation bank.
F. Stormwater M anagement and Diffuse Flow Plan (required by DWR)
Yes No
What type of SCM are you prov iding?
For a list of options to meet the diffuse flow requirements, click here.
Diffuse Flow Docume ntation
2. Stormw ater Management Plan
2a. Is this a NCDOT proje ct subje ct to compliance with NCDOT’s Indiv idual NPDES pe rmit NCS000250?*
2b. Doe s this proje ct me e t the re quire me nts for low de nsity proje cts as de fine d in 15A NCAC 02H .1003(2)?*
To look up low density requirement click here 15A NCAC 02H .1003(2).
2c. Doe s this proje ct hav e a stormwate r manage me nt plan (SM P) re v ie we d and approv e d unde r a state stormwate r program or state-approv e d local gov e rnme nt stormwate r
program?*
2d. Which of the following stormwate r manage me nt program(s) apply (che ck all that apply):*
Local Gov e rnme nt Stormwate r Programs *
Ple ase ide ntify which local gov e rnme nt stormwate r program you are using.*
Comme nts:
1. Environmental Documentation
1a. Doe s the proje ct inv olv e an e xpe nditure of public (fe de ral/state /local) funds or the use of public (fe de ral/state ) land?*
2. Violations (DWR Requirement)
2a. Is the site in v iolation of DWR Wate r Quality Ce rtification Rule s (15A NCAC 2H .0500), Isolate d We tland Rule s (15A NCAC 2H .1300), or DWR Surface Wate r or We tland Standards or
Riparian Buffe r Rule s (15A NCAC 2B .0200)?*
3. Cumulative Impacts (DWR Requirement)
3a. Will this proje ct (base d on past and re asonably anticipate d future impacts) re sult in additional de v e lopme nt, which could impact ne arby downstre am wate r quality?*
3b. If you answe re d “no,” prov ide a short narrativ e de scription.
4. Sewage Disposal (DWR Requirement)
4a. Is se wage disposal re quire d by DWR for this proje ct?*
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this proje ct occur in or ne ar an are a with fe de rally prote cte d spe cie s or habitat?*
Level Spreader
Vegetated Conveyance (lower SHWT)
Wetland Swale (higher SHWT)
Other SCM that removes minimum 30% nitrogen
Proposed project will not create concentrated stormwater flow through the buffer
(check all that apply)
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File type must be PDF
Yes No
Yes No
Yes No
N/A - project disturbs < 1 acre
Hint: projects that have vested rights, exemptions, or grandfathering from state or locally implemented stormw ater programs or projects that satisfy state or locally-implemented stormw ater programs through use of community in-lieu programs should answ er no
to this question.
Local Government State
If you have a local government approval please include the SMP on their overall impact map.
Phase II NSW
USMP Water Supply
Apex
G. Supplementary Information
Yes No
Yes No
Yes No
This development is not likely to spur cumulative impacts.
Yes No N/A
5b. Hav e you che cke d with the USFWS conce rning Endange re d Spe cie s Act impacts?*
5d. Is anothe r Fe de ral age ncy inv olv e d?*
5e . Is this a DOT proje ct locate d within Div ision's 1-8?*
5f. Will you cut any tre e s in orde r to conduct the work in wate rs of the U.S.?*
5g. Doe s this proje ct inv olv e bridge mainte nance or re mov al?*
Link to the NLEB SLOPES document: http://saw-reg.usace.army.mil/NLEB/1-30-17-signed_NLEB-SLOPES&apps.pdf
5h. Doe s this proje ct inv olv e the construction/installation of a wind turbine (s)?**
5i. Doe s this proje ct inv olv e (1) blasting, and/or (2) othe r pe rcussiv e activitie s that will be conducte d by machine s, such as jackhamme rs, me chanize d pile driv e rs, e tc.?*
5j. What data source s did you use to de te rmine whe the r your site would impact Endange re d Spe cie s or De signate d Critical Habitat?*
Consultation Docume ntation Upload
6. Essential Fish Habitat (Corps Requirement)
6a. Will this proje ct occur in or ne ar an are a de signate d as an Esse ntial Fish Habitat?*
6b. What data source s did you use to de te rmine whe the r your site would impact an Esse ntial Fish Habitat?*
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 proje ct occur in or ne ar an are a that the state , fe de ral or tribal gov e rnme nts hav e de signate d as hav ing historic or cultural pre se rv ation status (e .g., National Historic
Trust de signation or prope rtie s significant in North Carolina history and archae ology)?*
7b. What data source s did you use to de te rmine whe the r your site would impact historic or arche ological re source s?*
7c. Historic or Pre historic Information Upload
8. Flood Zone Designation (Corps Requirement)
Link to the FEM A Floodplain M aps: https://msc.fema.gov/portal/search
8a. Will this proje ct occur in a FEM A-designate d 100-ye ar floodplain?*
8c. What source (s) did you use to make the floodplain de te rmination?*
Comme nts
M isce llane ous attachme nts not pre v iously re que ste d.
Yes No
Yes No
Yes No Unknown
Yes No
Yes No
Yes No
Yes No
Yes No
USFWS iPaC
Click the upload button or drag and drop files here to attach document
IPaC_ Tullamore.pdf 4.93MB
File type must be PDF
Yes No
Essential Fish Habitat Mapper
Yes No
HPOWEB 2.0
Click the upload button or drag and drop files here to attach document
HPOWEB 2.0 - Tullamore.pdf 780.7KB
File must be PDF
Yes No
Wake County iMaps
M iscellaneous
Click the upload button or drag and drop files here to attach document
File must be PDF or KMZ
*
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 Act”);
I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes (the “Uniform Electronic Transactions Act”);
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 :*
Signature *
Date
Signature
By checking the box and signing below, I certify that:
Scott Mitchell
7/7/2020