20031635 Ver 1_Complete File_20031229

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13
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Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E., Director
Division of Water Quality
Coleen H. Sullins, Deputy Director
Division of Water Quality
January 7, 2004
Rockingham County
DWQ Project No. 031635
Pipe Replacement on SR 1133 (Goose Road)
APPROVAL of 401 Water Quality Certification with Additional Conditions
Mr. J. M. Mills, P.E., Division Engineer
NCDOT Division 7
P.O. Box 14996
Greensboro, NC 27415
Dear Mr. Mills:
You have our approval, in accordance with the attached conditions and those listed below, to permanently
impact 24 linear feet and to incur 20 linear feet to temporary impact to an unnamed tributary to Little
Hogan's Creek in order to replace a pipe on SR 1133 (Goose Road) in Rockingham County. The project
should be constructed in accordance with your application dated December 18, 2003 (received December
29, 2003). After reviewing your application, we have decided that this fill is covered by General Water
Quality Certification Nos. 3366 and 3404 corresponding to the U.S. Army Corps of Engineers Nationwide
Permit Numbers 33 and 14. In addition, you should 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 only valid for the purpose and design that you described in your application except as
modified below. If you change your project, you must notify us, in writing, and send us 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 conditions. If total wetland fills for this project
(now or in the future) exceed one acre or stream impacts 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. Temporary or permanent herbaceous vegetation shall be planted on all bare soil within 15 days of
ground-disturbing activities to provide long term erosion control.
2. The culvert required for this project shall be installed in such a manner that the original stream profile is
not altered (i.e. the depth of the channel must not be reduced by a widening of the streambed).
Existing stream dimensions are to be maintained above and below locations of the culvert. The culvert
shall be installed one foot below the stream to allow for fish and other wildlife movement.
3. All work shall be performed during low flow (below bankful) conditions.
4. 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.
5. The presence of equipment in the channel 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.
N. C. 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)
[phone] (phone), 919-733-6893 (fax), (http://h2o.enr.state.nc.us/ncwetlands)
r-t-, .C-;- !t• i -R77-t,71-t.7d9,

NCDOT, Rockingham County SR 1133, DWQ # 031635
Page 2
January 7, 2004
6. Use of rip-rap for bank stabilization is to be minimized; rather, native vegetation is to be planted
when practical. If necessary, rip-rap must be limited to the stream bank below the high water mark,
and vegetation must be used for stabilization above high water.
7. Rock silt screens at culvert outlets shall be removed at project completion.
8. 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 measures
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.
9. 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.
10. 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 Resources has released the project.
11. 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.
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 that conforms to Chapter 150B 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.
NCDOT, Rockingham County SR 1133, DWQ # 031635
Page 3
January 7, 2004
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. Beth Barnes at 919.715.8394 or Mr. Daryl
Lamb in the Winston-Salem Regional Office at 336.771.4600.
Sincerely,
Attachment
K1' ek, P.E.
Pc: Wilmington District Corps of Engineers
John Thomas, USACE Wilmington Field Office
Daryl Lamb, NCDWQ Winston-Salem Regional Office
Central Files
File Copy
aoy issu
FILE COPY
0?? for Coy
STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY
GovERNOR
LYNDO TIPPETT
SECRETARY
December 18, 2003 ® 3 1 6 3 5
Ms. Beth Barnes
Wetlands/401 Unit
NC DENR Division of Water Quality
1650 Mail Service Center
Raleigh, NC 27699
(Seven Copies)
Mr. John Thomas
US Army Corps of Engineers
6508 Falls of the Neuse Suite 120
Raleigh,.NC 27615-6814
(Two Copies)
?C ? 9 ?p03
Subject: Rockingham County, Pipe Extension on Goose Road (SR 1133)
Project Number # 70.079106
To Whom It May Concern:
The North Carolina Department of Transportation (NCDOT) proposes to replace a 36 ft X 18 inch
RCP with a 60 ft X 36 inch RCP on Goose Road (SR 1133) in Rockingham County. The work is
proposed in order to increase lane width and improve traffic safety. This activity will result in
impacts to an unnamed tributart of Little Hogan's Creek. In an effort to obtain the necessary
permits for the subject pipe extension, we are providing a pre-construction notification application
with supporting documentation. We believe this project can be permitted under the Nationwide
Permit Numbers 14 and 33. This application is intended as a request for formal written
authorization from the USCOE for NWP 14 and 33. This application is also intended as a request for
written authorization from the NC Division of Water Quality for minor road crossing under General
Water Quality Certificates #3376 and #3404.
The following information is being provided to satisfy conditions of General Water Quality
Certification.

P. O. Box 14996 Greensboro, NC 27415-4996 Telephone No. [phone] Fax No. [phone]
?WQ # 031635
)6 Jan 2004 11:42:16 -0500
idings <[e-mail]>
ENR DWQ
Barnes <[e-mail]>
C.
>Hey Rob, this DOT project impacts a UT to Little Hogan's Creek in
>Rockingham Co. The DEO has this UT classified as WS-IV NSW. Please
>check to determine if this stream is 'C' or 'WS-IV NSW'. I can not
>write the 401 letter until I am certain of the classification. Thanks,
>Beth

r
1 of 1 1/6/2004 6:07 PM
sezn-Barnes wrote:
r?
PROJECT INFORMATION
Road Name SR Number Project Length
miles Classification
Goose Road SR 1133 N/A Rural
River Basin: DWQ
ID Water Quality
Designation % Impervious
Surface
Roanoke 16-19-3-(0.5) WS-IV NSW; N/A
Buffer Ruiesa Buffer Rule Conditions (where applicable)
No equest Exemption
Protected Species
Present Mapped Historic
Properties CAMA
AEC Essential Fishery
Habitat
No No No No
PIPE EXTENSION INFORMATION (SITE 1)
Site N/A Stream Type Intermittent
(Station)
Existing Pie 36'X 18" RCP Extend 60'X 36" RCP
Construction Diversion Channel Dewatering ABC Aggregate
Method Device
E/C Plan
Burial Depth 20% Date
Construction As soon as practicable Duration One day
Date
24 ft-enclosure; 20 linear ft-rip-rap dissipaters; 40 sf temporary sandbags and
Impacts (ft.) rock silt dam
Special
Conditions
Restoration Within 15 working days of the pipe extension the natural stream contours will
Plan be restored and seeded. Temporary silt screens will be cleaned and removed
following vegetation establishment.
RCP = reinforced concrete pipe; CMP = Corrugated metal pipe; CMPA = Corrugated metal pipe arch; E/C = Erosion
control. *A less intrusive dewatering device may be used in lieu of the one proposed.
P. O. Box 14996 Greensboro, NC 27415-4996 Telephone No. [phone] Fax No. [phone]
MINIMIZATION INFORMATION
Impacts will be minimized by strict enforcement of Best Management Practices for the protection of
surface waters and wetlands, restrictions against the staging of equipment in or adjacent to waters
of the US, and coordination (including a pre-construction meeting) with the Division Environmental
Officer.
MITIGATION INFORMATION
Stream mitigation is not anticipated, as the impacts to any individual stream do not exceed 150 feet
Wetland mitigation is not anticipated, as wetland impacts do not exceed 0.10 acres and do not
occur in a unique natural wetland.
APPLICATION INFORMATION
Enclosed please find the Pre-construction Notification Form and supporting documentation for the
above referenced project. If you have any questions or need any additional information, please
contact Jerry Parker at [phone]. Your time and effort are appreciated.
Sincerely,
A?&
P'qm'
. Mills, P.E.
Engineer, Division 7
Enclosures
CC: Barry Harrington, NCDOT
H. L. McDowell, III, PE, NCDOT
Henry Adkins, NCDOT
Jerry Parker, NCDOT
P. O. Box 14996 Greensboro, NC 27415-4996 Telephone No. [phone] Fax No. [phone]
Office Use Only: ® 316 3 ?orm Version May 2002
USACE Action ID No. DWQ No.
(If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A".)
1. Processing
1. Check all of the approval(s) requested for this project:
? Section 404 Permit ? Riparian or Watershed Buffer Rules
? Section 10 Permit ? Isolated Wetland Permit from DWQ
® 401 Water Quality Certification
2. Nationwide, Regional or General Permit Number(s) Requested: NWP 14 and 33
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 (verify availability with NCWRP prior to submittal of PCN), complete
section VIII and check here: ?
5. If your project is located in any of North Carolina's twenty coastal counties (listed on page
4), and the project is within a North Carolina Division of Coastal Management Area of
Environmental Concern (see the top of page 2 for further details), check here: ?
II. Applicant Information
1. Owner/Applicant Information
Name: Mr. J.M. Mills, P.E Division Engineer - Division 7
Mailing Address: P.O. Box 14996
Greensboro NC
Telephone Number: [phone] Fax Number: [phone]
E-mail Address: mmills @dot state.nc.us
2. Agent/Consultant 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: Not Applicable
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
Pagel of 8
M. 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: Goose Road (SR 1133)
2. T.I.P. Project Number or State Project Number (NCDOT Only): 7C.079106
3. Property Identification Number (Tax PIN): Not Applicable
4. Location
County: Rockingham Nearest Town: Stokesdale
Subdivision name (include phase/lot number): Not Applicable
Directions to site (include road numbers, landmarks, etc.):
The project is northeast of Greensboro near Stokesdale in Rockingham County. From I-40
near Greensboro, take exit 210 (NC 68) and head north to Stokesdale for appox. 13 miles.
Turn left on NC 158 West in Stokesdale and go 0.8 miles to Belews Creek Rd. Turn right on
Belews Creek Rd and go 0.1 miles to Ellisboro Road (SR 1110). Turn left on Ellisboro Rd
and travel 6 miles to Goose Road (SR 1133) on the right. Site is located approx. 0.48 miles
after the entrance to Goose Road.
5. Site coordinates, if available (UTM or Lat/Long): See the attached USGS M.
(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. Property size (acres): Not Applicable
7. Nearest body of water (stream/river/sound/ocean/lake): UT to Little Hogan's Creek
Page 2 of 8
8. River Basin: Roanoke
(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/mus/.)
9. Describe the existing conditions on the site and general land use in the vicinity of the project
at the time of this application: Residential and agricultural
10. Describe the overall project in detail, including the type of equipment to be used:
The project will involve paving an unpaved secondary road and bringingL the travel lane
shoulders ditchlines and drainage structures up to current standards. Travel lane widening
will be required to bring the road up to current standards. Standard shoulder widths will be
6'-8' with deviations shown on the attached site plan. Ditch widths will vary based onsite
conditions Proposed right-of-way width is illustrated on the attached site plan. Equipment
used will be standard road construction equipment (trackhoe grader backhoe and
bulldozer)
11. Explain the purpose of the proposed work: To upgrade an unpaved secondary road to a
paved secondary road Paving and widening are being conducted to reduce future
maintenance costs bring the road up to current construction standards, and increase traffic
safety.
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.
Not Applicable
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.
Not Applicable
VI. 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
Page 3 of 8
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. Provide a written description of the proposed impacts: Permanent stream impacts will
result from channel enclosure and placement of rip-rap energy dissipaters Temporary stream
impacts will result from placement of cofferdams (perennial and intermittent streams) and
siltscreens Silt screens placed in intermittent channels will be cleaned and removed following
vegetation establishment
2. Individually list wetland impacts below:
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***
N/A

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized clearing, graamg, mi,
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FRM), or FEMA-approved local floodpiain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at h-q://www.fema8ov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.) Indicate if wetland is isolated (determination of isolation to be made by USACE only).
List the total acreage (estimated) of all existing wetlands on the property: Not Applicable
Total area of wetland impact proposed: Not Applicable
3. Individually list all intermittent and perennial stream impacts below:
Stream Impact
Site Number
indicate on ma
Type of Impact* Length of
Impact
linear feet
Stream Name** Average Width of
Stream Before
Impact Perennial or
Intermittent?
leasespecify)
1133 Site A Pipe extension 24
20(tmp?
20 UT to Little Hogan's
Creek 4' Intermittent

* 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 loss/gain),
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.sov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.topozone.com,
www.mai)quest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: 24- enclosure (en
20- temporary (tmp) 20- rip rap (rp)
Page 4 of 8
4. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic
Ocean and any other water of the U.S.) below:
Open Water Impact
Site Number
indicate on ma
Type of Impact* Area of
Impact
acres Name of Waterbody
(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean, etc.
N/A

List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
5. 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.): Not Applicable
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.): Not Applicable
Size of watershed draining to pond: N/A Expected pond surface area: N/A
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
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
Pine extension activities are necessary to increase travel lane and shoulder width to current
construction standards Impacts will be minimized by strict enforcement of Best Mana eg ment
Practices for the protection of wetland and surface waters, restrictions against the staging of
equipment in or adjacent to waters of the US and coordination (including as pre-construction
meeting) with the Division Environmental Officer.
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.
Page 5 of 8
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/stringide.html.
1. 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.
A finding of insignificant impact is anticipated; therefore, a mitigation plan is not provided.
Cumulative impacts are less than 150 feet The maximum amount of impact to a single
stream is 20 linear feet. No Outstanding Resource Waters, federally protected species or
their habitats or essential fiftU habitats occur in the project area The project is not located
in a High Quality Water.
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP). Please note it is the applicant's responsibility to contact the NCWRP at
[phone] to determine availability and to request written approval of mitigation prior
to submittal of a PCN. For additional information regarding the application process for the
NCWRP, check the NCWRP website at http://h2o.enr.state.nc.us/IM/index.htm. If use of
the NCWRP is proposed, please check the appropriate box on page three and provide the
following information:
Amount of stream mitigation requested (linear feet): Not Applicable
Amount of buffer mitigation requested (square feet): Not Applicable
Amount of Riparian wetland mitigation requested (acres): Not Applicable
Amount of Non-riparian wetland mitigation requested (acres): Not Applicable
Amount of Coastal wetland mitigation requested (acres): Not Applicable
Page 6 of 8
IX. Environmental Documentation (required by DWQ)
Does the project involve an expenditure of public (federal/state) funds or the use of public
(federal/state) 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 (required by DWQ)
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
(Meuse), 15A NCAC 2B ,0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes ? No H 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 N/A 3
2 N/A 1.5
Total N/A
* Zone i extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
Page 7 of 8
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.
Not Applicable
XI. Stormwater (required by DWQ)
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.
In accordance with the February 25, 1991 delegation agreement one copy of the sediment and
erosion control plan will be submitted to DENR - Division of Land Resources and NCDOT
Roadside Environmental Prior to construction.
XU. Sewage Disposal (required by DWQ)
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.
Not Applicable
XM. Violations (required by DWQ)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fast 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).
AP lican Agent's Signature Daie
(Agent's si nature is valid only if an authorization letter from the applicant is provided.)
Page 8 of 8
NCDOT
HAZARDOUS SPILL BASIN CHECKLIST
Division: 7 County
River Basin:
Route: 1133
Water Quality Criteria:
Rockingham
Roanoke
Project ID: 7C.079106
Bridge No: N/A
Stream: UT to Little Ho2an's Creek
Yes No
Stream Crossing Blue Line On USGS 0 ?
ORW ? 0
WSI ? El
WS 11,111 OR IV, Crossing Within 0.5mi of W.S. Critical Area ? 0
Roadway Criteria:
Route Designation-
Additional Site Information:
Yes No
Arterial Urban ? R
Arterial Rural ? R
Is a Hazardous Spill Basin Required?
Yes No
? E
Criteria Based Upon NCDOT "Best Management Practices for the
Protection of Surface Waters" (March, 1997).
20
116336
DAVID ROBERTS
CONNIE ROBERTS
DB 1014 - PG 2276
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DAVID ROBERTS
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DB 1014 - PG 2276
116302
R oCHHARRD D. BARNES
N REFERENCES AVAILABLE
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Name: ELLISBORO Location: 036° 19'26.3" N 079'58'24.3" W
Date: 12/11/2003 Caption: Goose Road Site (SR1133)
Scale: 1 inch equals 2000 feet Rockingham County
Copyright (C) 1997, Maptech, Inc.
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