20110044 Ver 1_Application_20110110

DEPARTMENT OF "TRANSPORTATION "^'a
BEVERLY EAVES PERDUE EUGENE A. CONTI, JR.
GOVERNOR SECRETARY
September 13, 2010
U. S. Anny Corps of Engineers
Wilmington District
Asheville Regulatory Field Office
151 Patton Avenue, Room 208
Asheville, NC 28801
ATTN: Ms. Liz Hair, NCDOT Coordinator
Subject: Application for Section 404 Nationwide Permit 23 for replacement of Bridge
139 over Beaverdam Creek on SR 1314 (Artee Road) in Cleveland County, State
Project No. 35560.1.1, Division 12, T.I.P'No. B-1 135.
The North Carolina Department of Transportation (NCDOT) proposes to replace bridge
number 139 over Overflow Creek (formerly identified as Beaverdam Creek) in Cleveland
County. There will be 67 feet of permanent surface water impacts and no temporary impacts.
These impacts occur as a result of the removal of the existing bridge and replacement with a 14
foot by10 foot double concrete box culvert.
Please see the enclosed copies of the Pre-Construction Notification (PCN), Stonmwater
Management Plan, permit drawings, and design plans for the above-referenced project. The
Programmatic Categorical Exclusion (PCE) was completed in August 2010. Additional copies
are available upon request. NCDOT is the only property owner for the jurisdictional stream
inside the Right-Of-Way.
STATE OF NORTH CAROLINA
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MAILING ADDRESS:
NC DEPARTMENT OF TRANSPORTATION
BRIDGE MANAGEMENT
1565 MAIL SERVICE CENTER
RALEIGH NC 27699-1565
TELEPHONE: [phone]
FAX: [phone]
LOCATION:
4809 Beryl Road
Raleigh, NC 27606
WEBSITE:w .NCDOi ORG

This project calls for a letting date of January 18, 2011 and a review date of November 30, 2010.
However, the let date may advance as additional funds become available. A copy of this permit
application will be posted on the NCDOT Website at: httl2://www.ncdot.org?doh/12reconstruct/pe/
neu. If you have any questions or need additional information, please call me at [phone].
.,
Sincerely,
Mike Summers, 'r
Project Manager
Bridge Management Unit
W/attachment
Mr. Brian Wrenn, NCDWQ (2 Copies)
W/o attachment (see website for attachments)
Dr. David Chang, P.E., Hydraulics Unit
Mr. Jason L. Willis, CPESC, CPSWQ, Division 12 Roadside Environmental Engineer
Mr. Greg Perfetti, P.E., Structure Design Unit
Mr. Victor Barbour, P.E., Technical Services Division
Mr. Jay Bennett, P.E., Roadway Design Unit
Mr. Majed Al-Ghandour, P. E., Program Development Branch
Mr. Art McMillan, P.E., Highway Design Branch
Ms. Marella Buncick, USFWS
Mr. Ricki Barkley, P.E., Division 12 Staff Engineer
Ms. Trish Simon, Division 12 Environmental Officer
13-1135 Pertiiit Application
Patye ? o F 2

MINIMUM CRITERIA DETERMINATION CHECKLIST
The following questions provide direction in determining when the Department is
required to prepare environmental documents for state-funded construction and
maintenance activities. Answer questions for Parts A through C by checking either yes
or no. Complete Part D of the checklist when Minimum Criteria Rule categories #8, 12i,
or #15 are used.
TIP Project No.: B-1135
State Project No.: WBS # 35560.1.1
Project Location: Bridge #139, SR 1314 (Artec Road), Cleveland County, NC
Project Description:
The North Carolina Department of Transportation (NCDOT) proposes to replace
Bridge No. 139 over Overflow Creek (previously identified as Beaverdam Creek)
on SR 1314 (Artee Road) in Cleveland County with a new culvert (see attached
vicinity map). The existing bridge is approximately 40 feet long and 27 feet wide
and will be replaced with a new 14 feet X 10 feet Double Barrel Reinforced
Concrete Box Culvert (RCBC) approximately 67 feet in length. The existing
bridge consists of 2 spans (one at 19 feet and one at 21 feet) with steel I-beams and
a timber deck with asphalt overlay superstructure supported by a combination of
timber piles and caps.
The new structure for Bridge No. 139 will consist of a double barrel (2@14 feet X
10 feet]) RCBC. In order to minimize disturbance to Overflow Creek (previously
identified as Beaverdam Creek), the RCBC will be countersunk one foot below
the existing grade of the streambed. The replacement RCBC begins at station
number I 1+00.00 and ends at 16+50.00. The project proposes symmetrical
widening improvements along the approaches of SR 1314. This section of SR
1314 will be closed during construction.
Anticipated Permit or Consultation Requirements:
Jurisdictional wetlands and surface waters fall under the broad category of
"Waters of the United States" as defined in 33 CFR § 328.3 and in accordance
with provisions of Section 404 of the Clean Water Act (33 U.S.C. 1344).
Jurisdictional "Waters of the United States" were identified within the project
study area in the form of a perennial stream known as Overflow Creek
(previously identified as Beaverdam Creek). A jurisdictional wetland delineation
was conducted in accordance with the criteria established in the USACE Wetlands
Delineation Manual (USACE, Corps Manual, 1987). Based on the field
investigations, no jurisdictional wetlands are located within the project study
area.
I of6
Dredging or placement of fill material into perennial streams requires permits
from the USACE and certification from the North Carolina Division of Water
Quality (NCDWQ). If impacts are less than 150 linear feet of perennial stream, a
General 401 Certification issued by NCDWQ and a Nationwide Permit (NWP)
issued by USACE may be applicable. A Pre-Construction Notification (PCN)
detailing the proposed activities is required and will be prepared and submitted to
the USACE. In addition, a USACE Nationwide #23 Permit for the
replacement of the existing bridge with a culvert in the stream is required
and will also be prepared and submitted for approval.
Best Management Practices (BMPs) for protection of surface waters must be
strictly adhered to in order to ensure the biological integrity of water bodies
impacted by this project. Strict enforcement of sedimentation control BMPs is
required for protection of surface waters during the entire life of the project.
During the final design and construction phases of the project, methods will be
incorporated to minimize impacts to aquatic and terrestrial ecosystems, and
reduce clearing and grubbing activities particularly in riparian areas.
Special Project Information:
The project site was reviewed by the Project Development and Environmental
Analysis Branch of NCDOT for cultural resources. The preliminary review
determined that there are no historic architecture or archaeological sites of any
significance within the project limits. No further surveys for cultural resources
are required.
2 of 6
PART A: MINIMUM CRITERIA
YES NO
Item I to be cbm vieted by the Engineer.
1. Is the proposed project listed as a type and class of activity allowed under I X1 U
the Minimum Criteria Rule in which environmental documentation is not
required?
If the answer to number 1 is "no", then the project does not quality as a
minimum criteria project. A state environmental assessment is required.
If yes, under which category? 9
If either category #8, #12i, or #15 is used complete Part D of this checklist.
PART B: MINIMUM CRITERIA EXCEPTIONS
Items 2 d to"be completed byby the Engineer.
2. Could the proposed activity cause significant changes in land use El concentrations that would be expected to create adverse air quality
impacts?
3. Will the proposed activity have secondary impacts or cumulative impacts
that may result in a significant adverse impact to human health or the
environment?
4. Is the proposed activity of such an unusual nature or does the proposed ?
activity have such widespread implications, that an uncommon concern
for its en vironmental effects has been expressed to the Department?
5. Does the proposed activity have a significant adverse effect on wetlands;
surface waters such as rivers, streams, and estuaries; parklands; prime or
unique agricultural lands; or areas of recognized scenic, recreational,
archaeological, or historical value?
6. Will the proposed activity endanger the existence of -a species on the F-1 N
Department of Interior's threatened and endangered species list?
7. Could the proposed activity cause significant changes in land use
concentrations that would be expected to create adverse water quality or
ground water impacts?
3 of6
YES NO
8. Is the proposed activity expected to have a significant adverse effect on
long-term recreational benefits or shellfish, finfish, wildlife, or their
natural habitats
If questions 5,6, or 8 are answered "NO" but a resource matching the description is
present, please explain in the "Special Project Information" section.
If any questions 2 through 8 are answered "YES", the proposed project may not qualify as a
Minimum Criteria project. A state environmental assessment (EA) may be required. For
assistance, contact:
Manager, Project Development and Environmental Analysis Branch
P. O. Box 25201
Raleigh, NC 27611
(919) 733 -3141
Fax: [phone]
PART C: COMPLIANCE WITH STATE AND FEDERAL REGULATIONS
mltems°9- 72 to'be completed by Division Etrvrronrnental Officer YES NO
9. Is a federally protected threatened or endangered species, or its ?
habitat, likely to be impacted by the proposed action?
10. Does the action require the placement of temporary or permanent ® ?
fill in waters of the United States?
11. Does the project require the placement of a significant amount of
fill in high quality or relatively rare wetland ecosystems, such as
mountain bogs or pine savannahs?
12. Is the proposed action located in an Area of Environmental ?
Concern, as defined in the coastal Area Management Act?
%tenes'13-75ato.be co»ipleted by the Engineer.`
13. Does the project require stream relocation or channel changes? ?
Cultural Resources
14. Will the project have an "effect" on a property or site listed on the F-1 N
National Register of Historic Places?
15. Will the proposed action require acquisition of additional right of
way from publicly owned parkland or recreational areas?
Questions in Part "C" are designed to assist the Engineer and the Division Environmental
Officer in determining whether a permit or consultation with a state or federal resource
agency maybe required. If any questions in Part "C" are answered "yes", follow the
appropriate pennitting procedures prior to beginning project construction.
4 of 6
PART D:( To be completed when either category #8, #12i, or #15 of the rules are
used.
7tunv 16= 22 to be: o_yleted by=Division'Envi?ronnientul Officer.;, b
16. Project length:
17. Right of Way width:
18. Project completion date:
19. Total acres of newly disturbed ground
surface:
20. Total acres of wetland impacts:
21. Total linear feet of stream impacts:
22. Project purpose:
5 of 6
If Part D of the checklist is completed, send a copy of the entire checklist document to:
Jason L. Willis, CPESC, CPSWQ, Division
State Roadside Environmental Engineer
PO Box 47
Shelby, NC 28151-0047
Phone [phone]
Fax [phone]
Email: [e-mail]
Reviewed by: /? -
aig You =, P
/Lead Engineer
ad/ ? JTishSimon
Division Environmental Supervisor
Date: 9 /3 /o
Date: -&'M-10
6
8000 Regency Parkway
Suite 200 Cary, C 27511
BUCK * P
h ne [phone]
E N G I N E E R I N G Fax: [phone]
wwwouckent,ineerinp.n
MEMO
To: Craig Young
From: Eric Mularski
Date: October 17, 2005
Re: Replacement of Bridge 139, Cleveland County; Environmental Screening/Natural Resources
Field investigations identifying jurisdictional wetlands and streams and conducting protected species
surveys were performed by a Buck Engineering biologist on October 10, 2005 for the referenced
project. The proposed project is the replacement of Bridge No. 139 located on SR 1314 (Artee Road)
over Beaverdann Creek, in Cleveland County. The proposed project replaces the bridge on existing
alignment. Field investigations were conducted within a project study area with the following
dimensions: 100 lira upstream and downstream of the bridge crossing and 500 Feet from each end of
the bridge. The project study area is characterized as rural with residential and forested areas. The
forestal areas most resemble a Piedmont/Low Mountain Alluvial Forest natural community as
described by Schnfale and Weakley (1990). The following dominant vegetative species occur within
the forest community: black walnut (Aaglans aigra), ndip poplar (Linodewho)i mlipifem), red maple
(Ater nibnmr), microstegimn (Microstegium vtinineuar), loblolly pine (Pinus meda), sycamore
(Platmrus occidentalis), dogwood (Cons flonda), honeysuckle (Lonicera japonica), river cane
(Anurelinaria glgantea), and tag alder (Aluus.serndata).
Wetlands and Surface Waters
Jurisdictional wetlands and surface waters Fall under the broad category of "Waters of the United
Stat&' as defined in 33 CFR § 328.3 and in accordance with provisions of Section 404 of the Clem
Water Act (33 U.S.C. 1344). Jurisdictional "Waters of the Unital States were identified within the
project study area in the fomn of a perennial stream known as Beaverdam Creek. A jurisdictional
wetland delineation was conductal in accordance with the criteria established in the USArnty Corps of
Engineer:c (USACE) Wetlands Delinertlion Manual (USACE, 1987). Based on the Add - Formatted: Font: Bold
im'estigations, no jurisdictional wetlands are located within the project study area.
permits
Dralging or placement of fill material into the perennial stream will raluire permits from the USACE
and certification firi DWQ. If impacts arc less than 150 In= feet of perennial stream, a General 401
Certification issued by DWQ and a Nationwide Pcrmit (NWP) issued by USACE may be applicable.
If the proposed replacement bridge does not dredge or place fill material into the perennial stream, then
a permit is not required; however, a Pre-Construction Notification (PCN) detailing the proposal
activities is required.
Best Management Practices (BMPs) for protection of surface waters, must be strictly adhered to ensure
the biological integrity of water bodies impacted by this project. Strict enforcement of sedimentation
control BMPs for protection of surface waters during the entire life of the project. During the design
and construction phases of the project, methods should be incorporated to minimize impacts to aquatic
and terrestrial ecosystems, and reduce clearing and grubbing activities particularly in riparian areas.
Protected Species Sunevs
Plants and animals with a fedet l classification of 9'hrcar ned (I) are protected under the provisions of
Section 7 and Section 9 of the Endangered Species Act of 1973. The table below lists one federally
protected species for Cleveland County (USFWS list updated February 5, 2003). In addition, the table
lists whether suitable habitat exists within the project study area and the biological conclusion for the
federally protected species.
Federally Protected S ecics listed for Cleveland County
Scienufe Natno. Common Name°.. Statnv, uitable, 'Riulo},ical
`tlahSitnt Present Cohehislon
Vascular Plants
Hesavi Us naniflora Dwarf-ROwced heartleal' T Yes No Ellect
Notes:
T 'I breatened denotes any native or once native species that is likely to become an Endangered species
within [he foreseeable future throughout all or a significant portion of its range, or one dert is designated as
a threatened species pursuant to the Endangered Species Act.
Heivaerylis nunffl nvt (Dwarf-flowered heartleal)
Biological Conclusion: No Effect
A review of the NCNHP database of rare species and unique habitats, conducted on October 17, 2005,
indicated no records ofoeeurrenees in the project study area or project vicinity. A field survey for
habitat and individual species within die pmject study area was conducted on October 10, 2005.
Suitable habitat was present in small isolated locations along Beaverdam Creek.. However, dwarf-
flowered heartleaf or other Herastylus species were not observed [luring the field survey. 'Hncrefore, it
is anticipated that project construction will have no effect on the dwarf-Flowered heartleaf.
Literature Cited
Sehofale, M. P. and A. S. Wetkley. 1990. Classification of the Natural Communities of North
Carolina: Third Approximation. North Carolina Natural Heritage Program, Division of Parks and
Recreation, North Carolina Department of Environment and Natural Resources. Raleigh, North
Carolina.
USACE. 1987. Wetlands Delineation Manual. Technical Report Y-87-1. US Amry Corps of
Engineers Watenvays Experiment Station, Vicksburg, Mississippi.
Dwarf-flowered heartleaf
USFWS optimal survey window: March-May
Habitat Description: Dwarf-flowered heartleaf is endemic to the western Piedmont and
foothills of North and South Carolina. This herbaceous evergreen is found in
moist to rather dry forests along bluffs; boggy areas next to streams and creek
heads; and adjacent hillsides, slopes, and ravines. Requiring acidic, sandy loam
soils, the species is found in soil series such as Pacolet, Madison, and Musella,
among others. Occurrences are generally found on a north facing slope.
Undisturbed natural communities such as Piedmont/Coastal Plain Heath Bluff,
Dry-Mesic Oak Hickory Forest, and Mesic Mixed Hardwood Forest hold the most
viable populations. However, less viable remnant populations are found in
disturbed habitats, including logged, grazed, mown, and residential/commercial
developed lands; areas converted to pasture, orchards, and tree plantations;
roadside rights-of-way; and on upland slopes surrounding manmade ponds or
lakes.
Biological Conclusion: May Affect - Not Likely to Adversely Affect
Suitable habitat for the Dwarf-flowered heartleaf is present in the study area along
roadside shoulders and stream side hillsides. Surveys were conducted by Michael Baker
Engineering, Inc. biologists throughout areas of suitable habitat on April 30, 2010. No
individuals of the Dwarf-flowered heartleaf were observed. A review ofNCNHP records,
updated May 28, 2009, indicates that the closest observed population is located approximately
0.65 miles from the study area and was last observed in April of 2001.
NatureServe. 2007. NatureServe Explorer: An online encyclopedia of life [web
application]. Version 6.2. NatureServe, Arlington, Virginia. Available
http://www.natureserve.org/explorer. (Accessed: February 22, 2008).
[NCNHP] North Carolina Natural Heritage Program. 2001. Guide to Federally Listed
Endangered and Threatened Species of North Carolina. Raleigh, NC. 134 pp.
Padgett, James Edward. 2004. Biogeographical, Ecological, Morphological, and
Micromorphological Analyses of the Species in the Hexastylis heterophylla Complex.
Appalachian State University, Boone, NC. 124 pp.
Schafale, M.P. and A.S. Weakley. 1990. Classification of the Natural Communities of
North Carolina: Third Approximation. Natural Heritage Program, Division of Parks and
Recreation, N.C. Department of Environment, Health, and Natural Resources. Raleigh,
NC. 325 pp.
[USFWS] U.S. Fish and Wildlife Service. 1989. Endangered and Threatened Wildlife
and Plants; Threatened Status of Hexastylis naniflora (Dwarf-flowered heartleaf). 54 FR
14964-14967.
[USFWS] U.S. Fish and Wildlife Service. 2006. Optimal Survey Windows for North
Carolina's Federally Threatened and Endangered Plant Species. http://www.fws.gov/aces/
es/plant_survey.html (Accessed: February 18, 2008).
[USFWS] U.S. Fish and Wildlife Service. 2007. Dwarf-flowered heartleaf (Hexas(vlis
naniflora) 5-Year Review: Summary and Evaluation, Draft. Asheville, NC. 51 pp.
f:?15 dao'fit1a:-1 7lP?+U 13?J' C<?tuitt: £3cre}ant3
GCTNCI:R Rf!:itiCl; FOIOI I?'OR'PitOPER I-I ES NOT E V IGIT3L I' l-'M
1 €7I: NATIONAl; R:F:t:IS'1 FIZ OF IITSTORIC I'I,A(E:'S .M
Plojee1 Drsc?iptlon Rcplace'B:- ,?-e:No, 139,ot) SR 1314 ovcrBeawrdarn Greet;
(in 046 "266C;.rpprescmnm-es of the
? Nonh Carolina Deparituettt of Trallcpor€ahun`(_NCDO F)
? ,,- [edarall-AahuavAcintuzs?tr?tion{17PJ?A)
:North Carohna Stue'fltstont.Pmcnahun Uflncc{HPC1}
R ,ricu cd the subject projc..-at
? sc"Ping ill Uing
y
Q- lYnston.is:n?uttctural rcanurces piholog;aph revio scKsirihhatnsuhwiimt
Criltcr
,111.1+?r]ie4.,?resriC tt;*r<it
? Thcaearc:no propmic;, over fffiv year., old widen the pri,je,l stared-of Potential of tctti_
Fherc ar,rnu ltrCopattici lusa than fifty ,Ycals old which arc: cmnadets:dao meet Criteria Consideratma f within the
prtlcct'sarea of potential: effccts,
EI Chem are propcrtiea over, f il'ty.;years olci within thu prnj ctts i resi oCEolen ini FtTeL.. (AN-1), but based on.die-
hisnricaLitniorruation a%aila'hlc and the phatogtaplis of vauh property, the progeny Mentified as -
> ? i rsf. l ltit-. is considered not chrihlc for ibe Nniioni l
Rc"ister and ne litnhct Mtluation ,fit is nccc arv.
[r}'? Chore arc to National Rc gi5ler-lisietI or Study f tested pntpcrnes withits (he vt>jdet'3 area of potential efYirats-
All propcn cti greater than )6 sears of age lo??w in the AP have hecn conbid,:rcd at der curvsultation, and hascd
opoll lfw ZLbuae Cor'.cilrrl'nce, rill conepliance:for hiswa , architecturewith Section 166 of the National Historic:
Preseregiimi Act and GS 1' 1-1?t'af has beco aamplefed for this project.
? 'There arc no historic, ptopertlcs. affected by thi pto)ca (,,larch am nores of document-5 as ewcdcd?
SH-nied

Kcprescntntivc,
fortheDvi, ion Adnimorator. or other Fc&raF A.otech Date
Raprc.Lit ntic I1P:O Date
Lc I listaric Presemizioll,
Dale
It:a mrec report i'. pre:pered a final-cop of this ferm.ard the; t hvd lice will he inctutied.
A
JAIL 1 (J o, ,,
o TD4yR. WATER C1Ui:iITY
AND STORMyyATEtt BRduru
Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Pre-Construction Notification (PCN) Form
A. Applicant Information
1. Processing
la. Type(s) of approval sought from the

Corps:
®Section 404 Permit El Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: 23 or General Permit (GP) number:
1c. Has the NWP or GP number been verified by the Corps? ? Yes ® No
Id. Type(s) of approval sought from the DWQ (check all that apply):
® 401 Water Quality Certification - Regular ? Non-404 Jurisdictional General Permit
? 401 Water Quality Certification - Express ? Riparian Buffer Authorization
le. Is this notification solely for the record
because written approval is not required? For the record only for DWQ 401
Certification:
® Yes ? No For the record only for Corps Permit:

? Yes ® No
1f. Is payment into a mitigation bank or in-lieu fee program proposed for mitigation
of impacts? If so, attach the acceptance letter from mitigation bank or in-lieu
fee program. ? Yes ® No
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h
below. ? Yes ® No
1h. Is the project located within a INC DCM Area of Environmental Concern (AEC)? ? Yes ® No
2. Project Information
2a. Name of project: Replacment of Bridge 139 over Beaverdam Creek on SR 1314
2b. County: Cleveland
2c. Nearest municipality / town: Lattimore
2d. Subdivision name: not applicable
2e. NCDOT only, T.I.P. or state
project no: B-1135
3. Owner Information
3a. Name(s) on Recorded Deed: North Carolina Department of Transportation
3b. Deed Book and Page No. not applicable
3c. Responsible Party (for LLC if
applicable): not applicable
3d. Street address: 1598 Mail Service Center
3e. City, state, zip: Raleigh, NC 27699-1598
3f. Telephone no.: [phone]
3g. Fax no. [phone]
3h. Email address: [e-mail]
r ?r?_yt±rt
4. Applicant Information (if different from owner)
4a. Applicant is: ? Agent ? Other, specify:
4b. Name: not applicable
4c. Business name
(if applicable):
4d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. Agent/Consultant Information (if applicable)
5a. Name: not applicable
5b. Business name
(if applicable):
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no..
5g. Email address:
B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID): not applicable
1b. Site coordinates (in decimal degrees): Latitude: 35.386993 Longitude: - 79.867931
(DD.DDDDDD) (-DD.DDDDDD)
1 c. Property size: 1.28 acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to Beaverdam Creek
proposed project:
21b. Water Quality Classification of nearest receiving water: C
2c. River basin: Broad
3. Project Description
3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application:
Land use: Rural residential, forested land, and outdoor recreation. Site and surrounding area forested with some
maintained edges.
3b. List the total estimated acreage of all existing wetlands on the property:
0
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
75 ft perennial -
3d. Explain the purpose of the proposed project:
Replace a structurally deficient bridge.
3e. Describe the overall project in detail, including the type of equipment to be used:
The project involves replacing a 41-foot long by 20-foot wide bridge with a 55-foot long by 30-foot wide 2-barrelled box
culvert on existing alignment with an off-site detour and temporary stream diversions as each side of the culvert is
constructed. Standard road building equipment, such as trucks, dozers, and cranes will be used..
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
? Yes ® No ? Unknown
project (including all prior phases) in the past?
Comments:
41b. If the Corps made the jurisdictional determination, what type ? Preliminary ? Final .
of determination was made?
4c. If yes, who delineated the jurisdictional areas? Agency/Consultant Company:
Name (if known): Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5. Project History
5a. Have permits or certifications been requested or obtained for ? Yes ® No ? Unknown
this project (including all prior phases) in the past?
5b. If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
6a. Is this a phased project? ? Yes ® No
6b. If yes, explain.
C. Proposed Impacts Inventory
1. Impacts Summary
la. Which sections were completed below for your project (check all that apply):
? 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.
2a. 2b. 2c. 2d. 2e. 2f.
Wetland impact Type of jurisdiction
number - Type of impact Type of wetland Forested (Corps - 404, 10 Area of impact
Permanent (P) or (if known) DWQ - non-404, other) (acres)
Temporary T
Site 1 ? P ? T ? Yes ? Corps
? No ? DWQ
Site 2 ? P ? T ? Yes ? Corps
? No ? DWQ
Site 3 ? P R T ? Yes ? Corps
? No ? DWQ
Site 4 ? P ? T ? Yes ? Corps
? No ? DWQ
Site 5 ? P ? T ? Yes ? Corps
? No ? DWQ
Site 6 ? P ? T ? Yes ? Corps
? No ? DWQ
2g. Total wetland impacts
2h. Comments:
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a. 3b. 3c. 3d. 3e. 3f. 3g.
Stream impact Type of impact Stream name Perennial Type of Average Impact length
number - (PER) or jurisdiction stream (linear feet)
Permanent (P) or intermittent (Corps - 404, 10 width
Temporary (T) (INT)? DWQ-non-404, (feel)
other)
Site 1 ? P ® T Fill from
Causeways geaverdam Creek ® PER
? INT ® Corps
? DWQ 32 43
Site 2 ® P D T Culvert Beaverdam Creek ® PER
? INT ® Corps
? DWQ 30 55
Site 3 ? P ? T ? PER ? Corps
? INT ? DWQ
Site 4 ? P ? T ? PER ? Corps
? INT ? DWQ
Site 5 ? P ? T ? PER ? Corps
? INT ? DWQ
Site 6 ? P ? T ? PER ? Corps
? INT ? DWQ
3h. Total stream and tributary impacts 55(P)
43(T)
3i. Comments: Two temporary causeways will be placed at the same time and used for removal of existing bents. The
causeways together cover less than half the stream.
4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individual) list all open water impacts below.
4a.
Open water
impact number -
Permanent (P) or
Temporary T 4b.
Name of
waterbody
(if applicable) 4c.

Type of impact 4d.

Waterbody type 4e.

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

Pond ID 5b.

Proposed use or 5c.
Wetland Impacts (acres) 5d.
Stream Impacts (feet) 5e.
Upland
(acres)
number purpose of pond
Flooded
Filled Excavat
ed
Flooded
Filled
Excavated
Flooded
P1
P2
5f. Total)
5g. Comments:
5h. Is a dam high hazard permit requi red?
? Yes ? No If yes, permit ID no:
5i. Expected pond surface area (acr es):
5j. Size of pond watershed (acres):
5k. Method of construction:
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer
impacts below. If an impacts require mitig ation, then you MUST fill out Section D of this form.
6a.
? Neuse
?Tar-Pamlico ? Other:
Project is in which protected basin? ? Catawba ? Randleman
6b. 6c. 6d. 6e. 6f. 6g.
Buffer impact
number - Reason for impact Buffer Zone 1 impact Zone 2 impact
Permanent (P) or Stream name mitigation (square feet) (square feet)
Temporary T required?
B1 ?P?T ?Yes
? No
B2 ?P?T ?Yes
? No
B3 ?P?T ?Yes
? No
6h. Total buffer impacts
6i. Comments:
D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
The proposed culvert is 43.5 feet shorter than the existing bridge, minimizing impacts to Beaverdam Creek. The proposed
culvert will be at approximately the same grade as the existing structure, and an off site detour will be used.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Best Management Practices for Surface Waters will be incorporated.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State? ? Yes ® No
If no, explain: Temporary impacts
2b. If yes, mitigation is required by (check all that apply): ? DWQ ? Corps

2c. If yes, which mitigation option will be used for this

project? ? Mitigation bank

El Payment to in-lieu fee program

? Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank: not applicable
3b. Credits Purchased (attach receipt and letter) Type Quantity
3c. Comments:
4. Complete if Making a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached. ? Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature: ? warm ? cool ?cold
4d. Buffer mitigation requested (DWQ only): square feet
4e. Riparian wetland mitigation requested: acres
4E Non-riparian wetland mitigation requested: acres
4g. Coastal (tidal) wetland mitigation requested: acres
4h. Comments:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
6. Buffer Mitigation (State Regulated Riparian Buffer Rules) - required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires.
buffer mitigation? ? Yes ? No
i
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.

Zone 6c.
Reason for impact 6d.
Total impact
(square feet)
Multiplier 6e.
Required mitigation
(square feet)
Zone 1 3 (2 for Catawba)
Zone 2 1.5
6f. Total buffer mitigation required:
6g. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in-lieu fee fund).
6h. Comments:
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
la. Does the project include or is it adjacent to protected riparian buffers identified ? Yes ® No
within one of the NC Riparian Buffer Protection Rules?
tb. If yes, then is a diffuse flow plan included? If no, explain why.
? Yes ? No
Comments:
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project? N/A
2b. Does this project require a Stormwater Management Plan? ® Yes ? No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, na rrative description of the plan:
See attached permit drawings.
? Certified Local Government
2e. Who will be responsible for the review of the Stormwater Management Plan? ? DWQ Stormwater Program
' ? DWQ 401 Unit
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project? not applicable
? Phase II
E] NSW
3b. Which of the following locally-implemented stormwater management programs ? USMP
apply (check all that apply): ? Water Supply Watershed
? Other:
3c. Has the approved Stormwater Management Plan with proof of approval been ? Yes ? No
attached?
4. DWQ Stormwater Program Review
? Coastal counties
4a. Which of the following state-implemented stormwater management programs apply ? HOW
(check all that apply): ? ORW
? Session Law 2006-246
? Other:
4b. Has the approved Stormwater Management Plan with proof of approval been
? Yes ? No
attached?
5. DWQ 401 Unit Stormwater Review
5a. Does the Slormwater Management Plan meet the appropriate requirements? ® Yes ? No
51b. Have all of the 401 Unit submittal requirements been met? ® Yes ? No
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
la. Does the project involve an expenditure of public (federal/state/local) funds or the ® Yes ? No
use of public (federal/state) land?
1b. If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State ® Yes ? No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1c. If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
letter.) ® Yes ? No
Comments:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Welland Rules (15A NCAC 2H .0500), Isolated
Welland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards, ? Yes ® No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b. Is this an after-the-fact permit application? ? Yes ® No
2c. If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in ? Yes
additional development, which could impact nearby downstream water quality? ® No
3b. If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short narrative description.
Due to the minimal transportation impact resulting from this bridge replacement, this project will neither influence nearby
land uses nor stimulate growth. Therefore, a detailed indirect or cumulative effects study will not be necessary.
4. Sewage Disposal (DWQ Requirement)
4a. Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility.
not applicable
10
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a . Will this project occur in or near an area with federally protected species or ? Yes ® No
habitat?
5b . Have you checked with the USFWS concerning Endangered Species Act ? Yes ® No
impacts?
Raleigh
El
5c . If yes, indicate the USFWS Field Office you have contacted. ? A
h
ill
ev
e
s
5d . What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
NHP, USFWS website, and the NCDOT field surveys conducted in 2005 and 2010. Dwarf-flowered heartleaf was not
present. The Biological Conclusion of May Affect - Not Likely to Adversely Effect remains valid.
6. Essential Fish Habitat (Corps Requirement)
6a . Will this project occur in or near an area designated as essential fish habitat? ? Yes ®No
6b . What data sources did you use to determine whether your site would impact Essential Fish Habitat?
NMFS County Index
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a . Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation ? Yes ® No
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b . What data sources did you use to determine whether your site would impact historic or archeological resources?
NEPA Documentation
8. Flood Zone Designation (Corps Requirement)
8a . Will this project occur in a FEMA-designated 100-year floodplain? ® Yes ? No
8b . If yes, explain how project meets FEMA requirements: NCDOT Hydraulics Unit coordination with FEMA
8c. What source(s) did you use to make the floodplain determination? FEMA Maps
Mike Summers. 2? *lrp ? rJ 95 ?
' Date
Applicant/Agent
s Printed Name Applicant/Agent's Signature
(Agent's signature is valid only if an authorization letter from the applicant
is provided.)

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