20040131 Ver 1_Complete File_20040202

0?6\N V ATFRQG Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
?- Alan W. Klimek, P.E. Director
> Coleen H. Sullins, Deputy Director
p ^? Division of Water Quality
February 26, 2004
Cleveland County
DWQ Project No. 040131
SR 1619 (Bridge No. 187)
APPROVAL of 401 Water Quality Certification with Additional Conditions
Mr. M. L. Holder, P.E.
Division Engineer
N C Department of Transportation
Post Office Box 47
Shelby, North Carolina 28151
WETLANDS 140'9 GROUP
MAR 9 U04
f0!14
Dear Mr. Holder:
You have our approval, in accordance with the attached conditions and those listed below, to impact 40 linear feet of
stream bank around bridge piers adjacent to Knob Creek (40 linear feet of riprap) and install a 40 foot long,
temporary riprap work bench, in order to replace Bridge No. 187 on NCSR 1619 (Sand Pit Road) in Cleveland
County. The project must be constructed in accordance with the application dated January 23, 2004 (received
February 2, 2004), including the environmental commitments made in the application letter. After reviewing your
application, we have decided that this fill is covered by General Water Quality Certification Nos. 3404 and 3366,
corresponding to the U.S. Army Corps of 17.ngineers Nationwide Permit Numbers 14 and 33. In addition, you must
acquire any other federal, state or local permits before you proceed with your project including (but not limited to)
Sediment and Erosion Control, Non-Discharge and Water Supply Watershed regulations. This approval will expire
with the accompanying 404 Permit unless otherwise specified in the Water Quality Certification.
This approval is valid solely for the purpose and design described in your application (unless modified below).
Should your project change, you must notify the DWQ in writing and submit a new application. If the property is
sold, the new owner must be given a copy of this Certification and approval letter, and is thereby responsible for
complying with all the conditions. If total wetland fills for this project (now or in the future) exceed one acre, or of
total impacts to streams (now or in the future) exceed 150 linear feet, compensatory mitigation may be required as
described in 15A NCAC 2H .0506 (h) (6) and (7). For this approval to be valid, you must follow the conditions
listed in the attached certification and any additional conditions listed below.
1. Erosion and sediment control practices must be in full compliance with all specifications governing the proper
design, installation and operation and maintenance of such Best Management Practices in order to protect surface
waters standards:
a. The erosion and sediment control measures for the project must be designed, installed, operated, and
maintained in accordance with the most recent version of the North Carolina Sediment and Erosion
Control Planning and Design Manual.
b. The design, installation, operation, and maintenance of the sediment and erosion control treasures must
be such that they equal, or exceed; the requirements specified in the most recent version of the North
Carolina Sediment and Erosion Control Manual. The devices shall be maintained on all construction
sites, borrow sites, and waste pile. (spoil) projects, including contractor-owned or leased borrow pits
associated with the project.
c. For borrow pit sites, the erosion and sediment control measures must be designed, installed, operated,
and maintained in accordance with the most recent version of the North Carolina Surface Mining
Manual.
d. Any reclamation measures and implementation must comply with the reclamation in accordance with
the requirements of the Sedimentation Pollution Control Act.
919 N. Main St., Mooresville, NC 28115 Telephone: [phone] Fax: [phone]
Mr. M. L. Holder, P.E.
February 26, 2004
Page Two
2. No waste, spoil, solids, or fill of any kind shall occur in wetlands, waters, or riparian areas beyond the footprint
of the impacts depicted in the Preconstruction Notice Application. All construction activities, including the
design, installation, operation, and maintenance of sediment and erosion control Best Management Practices,
shall be performed so that no violations of state water quality standards, statutes, or rules occur.
3. Sediment and erosion control measures shall not be placed in wetlands or waters to the maximum extent
practicable. If placement of sediment and erosion control devices in wetlands and waters is unavoidable, they
shall be removed and the natural grade restored within six months of the date that the Division of Land Quality
has released the project.
4. NCDOT shall comply with any conditions or moratoriums requested by the NC Wildlife Resources Commission.
5. The riprap used for temporary fill must be clean rock and free of fines. All of this material must be removed by
the completion of the project.
6. Riparian vegetation must be reestablished within the construction limits of the project by the end of the growing
season following completion of construction.
7. Stortnwater should be directed to vegetated buffer areas, grass lined ditches or other means appropriate to the site
for the purpose of pre-treating stormwater runoff, and must not be routed directly into streams. Mowing of
existing vegetated buffers is strongly discouraged, so that they may be utilized for stormwater sheet flow.
8. Removal of vegetation at the stream crossing and adjacent to streams should be minimized. Native trees and
shrubs (e.g. Rhododendron, dog hobble, willows, alders, sycamores, dogwoods, black walnut and red maple)
should be planted along the streambank to reestablish the riparian zone and to provide long-term erosion control
in the vicinity of the road crossing and along the streams within dedicated rights of way.
9. Riprap placed for bank stabilization should be limited to the streambank below the high water mark, and
vegetation should be used for stabilization above the high water elevation.
10. Heavy equipment must be operated from the banks rather than in the stream channel in order to minimize
sedimentation and reduce the likelihood of introducing other pollutants into the stream.
11. All mechanized equipment operated near surface waters must be regularly inspected and maintained to prevent
contamination of stream waters from fuels, lubricants, hydraulic fluids, or other toxic materials.
12. Excavation of the stream crossings and relocations should be conducted in the dry, if possible. Sandbags,
cofferdams, flexible pipe or other diversion structures should be used to minimize excavation in flowing water.
13. If concrete is used during bridge construction (e.g., headwalls, piers), a dry work area should be maintained to
prevent direct contact between curing concrete and stream water. Water that inadvertently contacts uncured
concrete should not be discharged to surface waters due to the potential for fish kills.
14. Discharging hydroseed mixtures and washing out hydroseeders and other equipment in or adjacent to surface
waters is strictly prohibited.
15. The presence of equipment in the channels must be minimized. Under no circumstances must rock, sand or other
materials be dredged from the wetted stream channel under authorization of this permit, except in the immediate
vicinity of the culverts. Instream dredging has catastrophic effects on aquatic life and disturbance of the natural
form of the stream channel will likely cause downstream erosion problems, possible affecting other landowners.
16. All work shall be performed during low flow conditions.
17. Upon completion of the project, the NCDOT shall complete and return the enclosed "Certificate of Completion"
form to notify NCDWQ when all work included in the §401 Certification has been completed. The responsible
party shall complete the attached form and return it to the 401/Wetlands Unit of the NC Division of Water
Quality upon completion of the project. NCDOT is strongly advised to send in photographs upstream and
downstream of each structure to document correct installation.
If you do not accept any of the conditions of this certification, you may ask for an adjudicatory hearing. You must
act within 60 days of the date that you receive this letter. To ask: for a hearing, send a written petition, which
conforms to Chapter 1.50B of the North Carolina General Statutes to the Office of Administrative Hearings, 6714
Mail Service Center, Raleigh, N.C. 27699-6714. This certification and its conditions are final and binding unless you
ask for a hearing.
Mr. M. L. Holder, P.E.
February 26, 2004
Page Three
This letter completes the review of the Division of Water Quality under Section 401 of the Clean Water Act. If you
have any questions, please telephone Ms. Cynthia Van Der Wiele at 919.733.5715 or Mr. Mike Parker of the
Asheville Regional Office at 828.251.6208.
Sincerely,
PJ---
lan W. Klimek, P.E.
Attachment
cc: Wilmington District Corps of Engineers
Trish Simon, Division 12, DEO
Steve Lund, USACE Asheville Field Office
Mooresville Regional Office
Wetlands/401 Unit
Mike Parker, NCDWQ Asheville Regional Office
MEMORANDUM
TO: John Dorney Regional Contact:
Non-Discharge Branch WO Supervisor:
Date:
SUBJECT: WETLAND STAFF REPORT AND RECOMMENDATIONS
Facility Name NCDOT - Bridge 187 on SR 1619
Project Number 04 0131
Recvd From DOT
County CLEVELAND
County2
Region Mooresville
Received Date 2/2/04 Recvd By Region
Project Type replace bridge with bridge
Certificates Stream
Permit Wetland Wetland Wetland Stream Class Acres
Type Type Impact Score Index Prim. Supp. Basin Req.
Stream Impacts (ft.)
Feet
Req.
14 Stream P-17-0 " I 9-50-19 F-C _F- 30,804. F- 80.00 80.00
F_33F_ O Y O N F-F-F-F--F--F--
Mitigation Wetland
MitigationType Type Acres Feet
Is Wetland Rating Sheet Attached? 0 Y .O N Did you request more info? 0 Y 6 N
Have Project Changes/Conditions Been Discussed With Applicant? 0 Y 0 N
Is Mitigation required? 0 Y 0 N Recommendation: 0 Issue 0 Issue/fond 0 Deny
Provided by Region: Latitude (ddmmss) 353046 Longitude (ddmmss) 813155
cc: Regional Office
Central Office Page Number 1
WETLANDS/ 401 GROUP
`? FED 0 ? ..2004
?••°""''• WATER QUALITY SECTION
STATE of NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY P.O. Box 25201, RALEIGH, N.C. 27611-5201 LYNDO TIPPETT
GOVERNOR SECRETARY
P.O. BOX 47,1710 East Marion Street
Shelby, N. C. 28151-0047
January 23, 2004
Mr. Steve Lund, NCDOT Projects
US Army Corp of Engineers
Asheville Regulatory Field Office
151 Patton Avenue, Room 208 040131
Asheville, N. C. 28801-5006
Dear Mr. Lund:
The North Carolina Department of Transportation, Division of Highways, request the issuance of
a Section 404 Permit, Nationwide Permit #14, Maintenance and #33, Temporary Construction,
Access, and Dewatering.
COUNTY: Cleveland
LOCATION: Bridge #187, SR 1619, north of Belwood
STREAM: Knob Creek (Big Knob Creek), Class C Waters (from source to a point
0.3 miles downstream of Adams Creek), Broad River Basin
PROJECT DESCRIPTION: The project consists of the replacement of an existing 12'wide x
40' long timber bridge with a 33' wide x 95' long concrete bridge. The increase in bridge length
will allow for the removal of the existing timber abutments that are currently constricting stream
flow, therefore reestablishing a natural stream section. Riprap will be placed for on the
streambanks for 40 linear feet around the bridge piers to provide structure stabilization. The use
of riprap will not exceed the quantity necessary to protect the new bridge substructure. A 40-foot
long temporary riprap workbench will be utilized to install the north bridge piers. Upon project
completion, the temporary workbench will be removed and the stream dimensions restored. I
have enclosed a PCN application, a sketch of activities- including preliminary erosion control
sketch and location maps relative to the project.
Mr. Steve Lund
BR#187, SR 1619, Cleveland County
Page Two
The proposed project is located in Class C waters; therefore, hazardous spill basins are not
required. Enclosed is the NCDOT hazardous spill basin checklist for this project.
A review of the Natural Heritage information for the threatened species listed for Cleveland
County, the dwarf-flowered heartleaf (Hemsiylis nan flora), revealed no known sites in the
vicinity of the project area. A survey for the heartleaf species was conducted on January 20, 2004
in the vicinity of the proposed project. It was determined that no heartleaf species was located in
the project area; therefore, no impact is anticipated. A review of the available information from
the National Register of Historic Places was also conducted. No historic sites will be affected by
the project.
Your earliest consideration for this request would be greatly appreciated. Should you have any
questions, please call me at 704-480-9020.
Respectfully yours,
M.L. Holder, P.E.
Division Engineer
Twelfth Division
BY:
Trish Simon
Division 12 Environmental Supervisor
Enclosures
cc: Mr. Michael L. Holder, P.E., Division Engineer
Mr. Dan Holderman, P.E., Division Bridge Engineer
Mr. Jason Willis, Roadside Environmental Field Operations
Mr. Mike Parker, DENR, DWQ, Asheville Regional Office
Mr. John Dorney, DENR, DWQ, 401/Wetlands Unit
Mr. Ron Linville, N.C. Wildlife Resources Commission
Mr. Brian Cole, U. S. Fish & Wildlife Service
File
Office Use Only: Form Version October 2001
USACE Action ID No. DWQ No0.40131
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
I. Processing
1. Check all of the approval(s) requested for this project:
® Section 404 Permit
? Section 10 Permit
®401 Water Quality Certification
? Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: Nationwide Permit #14, 933
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: ?
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here: ?
EL Applicant Information
1. Owner/Applicant Information
Name: Mike Holder NCDOT
Mailing Address: P.O. Box 47
Shelby, NC 28151
Telephone Number: 704-480-9020 Fax Number: 704-480-5401
E-mail Address:
2. Agent Information (A signed and dated copy of the Agent Authorization letter must be
attached if the Agent has signatory authority for the owner/applicant.)
Name: _ Trish Simon
Company Affiliation: NCDOT
Mailing Address: P.O. Box 47
Shelby, NC 28151
Telephone Number: 704-480-9044 Fax Number: 704-480-5401
E-mail Address: [e-mail]. nc us
Page I of 7
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project: Replacement of Bridge #187 Sand Pit Road. SR 1619. Cleveland County
2. T.I.P. Project Number or State Project Number (NCDOT Only): 37495
3. Property Identification Number (Tax PIN): N/A
4. Location
County: Cleveland Nearest Town: Belwood
Subdivision name (include phase/lot number): NA
Directions to site (include road numbers, landmarks, etc.): Hwy 18 north from Shelby. turn
left onto SR 1619 Sandpit Rd project site first bridge (#187)
5. Site coordinates, if available (UTM or Lat/L.ong): 35° 30'46" N. 81' 31' 55" W
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Describe the existing land use or condition of the site at the time of this application:
NCDOT right-of-way
7. Property size (acres): 0.2 acres
8. Nearest body of water (stream/river/sound/ocean/lake): Knob Creek
9. River Basin: Broad
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/maps/.)
10. Describe the purpose of the proposed work: The project consists of replacing a structurally
deficient and functionally obsolete 12' wide x 40' long timber bridge with a 33' wide x 95'
long concrete bridge.
Page 2 of 7
11. List the type of equipment to be used to construct the project: Drilling rig, crane, and
trackhoe will be used for construction.
12. Describe the land use in the vicinity of this project: Cultivated croplands, cow feeding lot,
and woodlands.
IV. Prior Project History
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.
V. Future Project Plans
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application:
No future permit requests anticipated.
VL Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the impact in Section VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
1. Wetland Impacts: NONE
Wetland Impact
Site Number
indicate on ma
Type of Impact* Area of
Impact
(acres) Located within
100-year Floodplain**
es/no Distance to
Nearest Stream
linear feet
Type of Wetland***

* List each impact separately and identify temporary impa°ts. Impacts include, but are not limited to: mechanized clearing, grading, fill,
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both stnwc and flooding.
** 100-Year floodplams are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at httn://www. fema. gov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.)
Page 3 of 7
List the total acreage (estimated) of existing wetlands on the property: 0
2. Stream Impacts, including all intermittent and perennial streams
Stream
Impact Site Length of Impact Average Width Perennial or
Number Type of Impact*
sm
ear feet) **
Stream Name**
of Stream
Intermittent?
(indicate on Before Impact (please specify)
ma
Riprap on
I streambank for 40 feet Knob Creek 25 feet Perennial
structure stabilization
1 Temporary bench 40 feet "
List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net losstgain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
www.usgs.eov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.topozone.com,
www.mapquest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: 40' permanent streambank
impacts and 40' temporary stream impacts.
Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U. S. NO OPEN WATER MACTS
Open Water Impact Area of Name of Wateibody Type of Waterbody
Site Number Type of Impact* Impact (if applicable) (lake, pond' estuary, sound'
indicate on ma acres bay, ocean, etc.

" List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. Pond Creation NO POND CREATION
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): ? uplands ? stream ? wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
Page 4 of 7
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
The deficient bridge is being replaced with another bridge. therefore. there is no net loss of linear
stream footage The proposed bridge length will allow removal of the existing timber abutments
that are currently constricting stream flow therefore reestablishing a natural stream section. The
use of riprap will be limited to the quantity necessary to protect the new bridge substructure
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
http://h2o.enr.state.nc.us/ncwetlands/strmizide.html.
Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
IMPACTS < 150 FEET, MITIGATION NOT ANTICIPATED
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at http://h2o.cnr.state.nc.us/wrp/index.htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Page 5 of 7
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/stateAocal)
land?
Yes ® No ?
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ? No
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes ? No ?
X. Proposed Impacts on Riparian and Watershed Buffers (DWQ Only)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Neese), 15A NCAC 213 .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes ? No ® If you answered "yes", provide the following information:
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
*
Zone Impact
(square feet
Multiplier Required
Mitigation
1 3
2 1.5
Total
' Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
Page 6 of 7
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or.0260.
XL Stormwater (DWQ Only)
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
Additional impervious surface of 0.019 acres is proposed (increase in bridge widthl. Stormwater
will be directed off the proposed bridge deck via funnel drains into riprap lined ditchlines
XII. Sewage Disposal (DWQ Only)
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.
N/A
XM. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit application?
Yes ? No
XIV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).

Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Page 7 of 7
(Photo #1) One lane bridge (#187) over Knob Creek
looking downstream.
(Photo #3) Knob Creek looking
upstream from under bridge (#187).

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NCDOT
HAZARDOUS SPILL BASIN CHECKLIST
Division: / ?-- County: cc.ELifFc, 4 Project ID: 37+'7a-
River Basin:??,4,? Bridge No: /87
Stream: 1[ Ayv? C-
Route : 5, -o'
Water Quality Criteria:
Yes No
Stream Crossing Blue Line On USGS f:/' r
ORW r r?
WSI r r?
WS II1III OR IV, Crossing Within 0.5mi of W.S. Critical Area r r?
Roadway Criteria:
Route Designation-
Yes No
Arterial Urban r r?
Arterial Rural r r/
Additional Site Information:
Yes No
Is a Hazardous Spill Basin Required? r r?
Criteria Based Upon NCDOT "Best Management Practices for the
Protection of Surface Waters" (March, 1997).
WETLANDS / 401 G80IJp
n .2004
? .? WATER QuALi.
•??.?.• ly SECTION
STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY LYNDO TIPPETT
GOVERNOR SECRETARY
0401 31
MEMO TO: John Dorney, DENR/DWQ/401/Wetlands Unit
FROM: Trish Simon, Division 12 Environmental Supervisor O
DATE: January 23, 2004
SUBJECT: Pre-Construction Notification/401 Automated Payment
Enclosed are seven copies of a pre-construction notification for a NCDOT project in
Cleveland County for your review.
Project information for the 401 Automated Payment Procedure
• Work order number: 150465-55120005-37495-4686-49360
• TIP #: NA
• Project Category: $200.00 Fee
is

Post Office Box 47 Shelby, North Carolina 28 1 5 1-0047
O?O? W AT jSRQG
r
O '<
DWQ Project No.: 04-0161 County:
Applicant: ?? aT - ??ciis<?.J /Z
Project Name: lL??/fcG?r?? OG
Date of Issuance of 401 Water Quality Certification:

Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification or applicable Buffer
Rules, and any subsequent modifications, the applicant is required to return this certificate to the
401/Wetlands Unit, North Carolina Division of Water Quality, 1650 Mail Service Center, Raleigh, NC,
27699-1650. This form may be returned to DWQ by the applicant, the applicant's authorized agent, or
the project engineer. It is not necessary to send certificates from all of these.
Applicant's Certification
I, JV 1 - L. 6 (c(er , hereby state that, to the best of my abilities, due care
and diligence was used in the observation of the construction such that the construction was observed to
be built within substantial compliance and intent of the 401 Water Quality Certification and Buffer
Rules, the j lans and specifications, and other supporting materials.
Signature. II``jj????`//''????? Date:
Agent's Certification
I, , hereby state that, to the best of my abilities, due care
and diligence was used in the observation of the construction such that the construction was observed to
be built within substantial compliance and intent of the 401 Water Quality Certification and Buffer
Rules, the approved plans and specifications, and other supporting materials.
Signature: Date:
If this project was designed by a Certified Professional
I, , as a duly registered Professional (i.e.,
Engineer, Landscape Architect, Surveyor, etc.) in the State of North Carolina, having been authorized
to observe (periodically, weekly, full time) the construction of the project, for the Permitee hereby state
that, to the best of my abilities, due care and diligence was used in the observation of the construction
such that the construction was observed to be built within substantial compliance and intent of the 401
Water Quality Certification and Buffer Rules, the approved plans and specifications, and other
supporting materials.
Signature Registration No. Date

Michael F. Easle or
William G. Ross Jr.,
North Carolina Department of Environment d Natural Res
Alan W. lipnek, Dir
Divi t?.pf W Qua
lr+??1
rE?M
North Carolina Division of Water Quality, 401 Wetlands Certification Unit,
1650 Mail Service Center, Raleigh, NC 27699-1650 (Mailing Address)
2321 Crabtree Blvd., Raleigh, NC 27604-2260 (Location)
919-733-1786 (phone), 919-733-6893 (fax), http://h2o.enr.state.nc.us/ncwetiands/
.

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