HomeMy WebLinkAbout20060296 Ver 1_Complete File_20060315
Certificate of Completion
DWQ Project No. O U - 0?- I County: CJ cV e-) an
Applicant: NciJ0O-' -b -1 y 12
Project Name: SlZ 19 2.,1 C r ' ? tI I ar, 1?-d J
Date of Issuance of 401 Water Quality Certification: rc.V-\ 15. 2,DOU
Upon completion of all work approved within the 401 Water Quality Certification and 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, 1621 Mail Service Center, Raleigh,
NC, 27699-1621. 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, 1Y) - L- 14nId-,P- r , 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
built within substantial compliance and intent of the 401 Water Quality Certification and Buffer
Rules, the approved plans and sp cifications, and other supporting materials.
Signature: ?'?• Date: -0?
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
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:
If this project was designed by a Certified Professional
Date:
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
Permittee 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 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:
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Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, F.E. Director
Division of Water Quality
March 15, 2006
DWQ# 06-0296
Cleveland County
Mr. Mike Holder, P.E.
NCDOT Division 12
P.O. Box 47
Shelby, NC 28151
APPROVAUMODIFICATION of 401 Water Quality Certification with Additional Conditions
Dear Mr. Holder:
You have our approval, in accordance with the attached conditions and those listed below, to permanently
impact 20 linear feet (If) (10 If for culvert length increase, 10 If for riprap inlet/outlet protection) of an unnamed
tributary to Mayne Creek* to replace an existing, deteriorating culvert as described in your application received
by the Division of Water Quality (DWQ) on February 24, 2006. The location of the project is State Road 1421
(Mellon Road) in Cleveland County. After reviewing your application, we have determined that this project is
covered by Water Quality General Certification Number 3404. Please note that you should get any other
federal, state or local permits before proceeding with your project, including those required by (but not limited
to) Sediment and Erosion Control, Non-Discharge, and Water Supply Watershed regulations.
This approval is valid solely for the purpose and design that you described in your application (unless modified
below) and will expire with the associated USACE 404 permit unless otherwise specified in the Water Quality
Certification. Should your project change, you must notify the DWQ in writing and you may be required to
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 conditions. If total wetland fills for this project
(now or in the future) exceed one acre, or if 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 remain valid, you must adhere to the conditions in the attached certification and those listed below:
The placement of culverts and other structures in waters, streams and wetlands must be below the elevation
of the streambed by one (1) foot for all culverts with a diameter greater than 48 inches, and 20 percent of the
culvert diameter for culverts having a diameter less than 48 inches, to allow for low flow passage of water and
aquatic life, as well as prevent headcutting of the streams. Design and placement of culverts and other
structures including temporary erosion control measures shall be installed in such a manner that the original
stream profiles are not altered (i.e., the depth of the channel must not be reduced by a widening of the
streambed). Existing stream dimensions (including pattern and profile) are to be maintained above and
belnyn f ° h t, Th pl; nt m r n r! rl }n rr v irln fw;, nvir`n 4 ?t the e#1 1!llhritlrr has
o -vu ? i, rFl:'J 1` ? :, .1 - h: f,^ 1i.1 , 1. .
been maintained, if requested in writing by the DWQ.
2. Riprap must not interfere with thalweg performance and aquatic life passage during low flow conditions.
Riprap placed for bank stabilization should be limited to the stream bank below the high water mark and
vegetation should be used for stabilization above the high water mark.
*No stream determination performed.
North Carolina Division of Water Quality 610 East Center Avenue, Suite 301
Internet: .nc alrnlualit ,i,r_ Mooresville, NC 28115
Phone(704)663-1699
FAX (704) 663-6040
N e hCarolma
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An Equal Opportunity/Affirmative Action Employer - 50% Recycled/10% Post Consumer Paper
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3. Heavy equipment must be operated from the banks rather than in the stream channel, when possible, in
order to minimize sedimentation and reduce the likelihood of introducing other pollutants into the stream.
4. Temporary dewatering sites must be restored to pre-existing conditions unless more natural geomorphic
conditions can be provided.
5. No live or fresh concrete shall come into contact with waters of the state until the concrete has hardened.
6. The dimension, pattern and profile of the stream above and below the crossing should not be modified.
Disturbed floodplains and streams should be restored to natural geomorphic conditions.
7. 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.
8. All work shall be performed during low or normal flow conditions.
9. Discharging hydroseeding mixtures and washing out hydroseeders and other equipment in or adjacent to
surface waters is strictly prohibited.
10. Erosion and sediment control practices must utilize Best Management Practices (BMP) and be in full
compliance with all specifications governing the proper design, installation, and operation and maintenance of
such BMP in order to protect surface water standards:
a. 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 pit sites, and waste pile (spoil) projects, including contractor-owned or
leased borrow pits associated with the project.
b. 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.
c. The reclamation measures and implementation of these measures must be in accordance with the
requirements of the Sedimentation Pollution Control Act.
11. 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 30 days after the Division of Land Resources has
released the project.
12. The North Carolina Department of Transportation (NCDOT) and its contractors and/or agents shall not
eXrra` -t. t" fill or ncrIn'*Y' f:l.!nn- nt -nv t;' " , irk fh- r.nnstri.-4inn nr rnc0nt-n n('A of thiC
project within waters and/or wetlands, except as authorized by this Certification, or any modification to this
Certification (e.g., no work shall occur outside of the footprint of the plans provided). In addition, there shall
be no excavation from or waste disposal into jurisdictional wetlands or waters associated with this
Certification without appropriate modification. If this occurs, compensatory mitigation may be required since it
is a direct impact from road construction activities.
13. Upon completion of the project, the applicant shall complete and return the enclosed "Certificate of
Completion" form to notify DWQ when all work included in the 401 Certification has been completed. Please
include photographs upstream and downstream of the structure to document correct installation.
Page 3
14. Continuing Compliance. NCDOT shall conduct its activities in a manner so as not to contravene any state
water quality standard [including any requirements for compliance with section 303(d) of the Clean Water Act]
and any other appropriate requirements of state and federal law. If DWQ determines that such standards or
laws are not being met (including the failure to sustain a designated or achieved use) or that state or federal
law is being violated, or that further conditions are necessary to assure compliance, DWQ may reevaluate
and modify this certification to include conditions appropriate to assure compliance with such standards and
requirements in accordance with 15 A NCAC 2H.0507(d). Before codifying the certification, DWQ shall notify
NCDOT and the USACE, provide public notice in accordance with 15A NCAC 2H.0503, and provide
opportunity for public hearing in accordance with 15A NCAC 2H.0504. Any new or revised conditions shall
be provided to NCDOT in writing, shall be provided to the USACE for reference in any permit issued pursuant
to Section 404 of the Clean Water Act, and shall also become conditions of the 404 Permit for 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.
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 Polly Lespinasse In the Mooresville Regional Office at 704-663-
1699.
Sincerely,
c%
for Alan W. Klimek, P.E.
Attachments
cc: Steve Lund, USACE Asheville Field Office
Rob Ridings, DWQ Wetlands Unit
Central Files
File Copy
1 1,35
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MAR 2 1 2006
?AV AT9MW#ATM BRANCH
STATE OF NORTH CAROLINA
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DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY DIVISION OF HIGHWAYS LYNDO TIPPETT
GOVERNOR SECRETARY
February 20, 2006
Mr. John Hennessy
401 /Transportation Permitting Unit O Cv Q
1650 Mail Service Center 0296
Raleigh, N.C. 27699-1650
SUBJECT: Pipe replacement, SR 1421, Cleveland County
Dear Mr. Hennessy:
The North Carolina Department of Transportation proposes to replace a failing pipe on SR 1421, Mellon
Road in Cleveland County. The end section of the pipe has broken off and caused the road shoulder to
collapse. The existing 50-foot long, 48" CW will be replaced with a 60-foot long, 60" CMP with inlet
headwall. The pipe is to be buried one foot below the streambed elevation based upon the thalweg profile.
This will result in a pipe slope of 4.7%; therefore, large riprap will be utilized at the pipe outlet to provide
energy dissipation. The rock will be embedded into the streambed; therefore, aquatic passage will be
maintained. A total of ten feet of riprap will be utilized for structure stabilization/rock energy dissipator.
The scope of the work will result in a 20 feet of permanent impacts to an unnamed tributary to Mayne
Creek (East Fork Sandy Run Creek), which is classified as Class C waters by the Division of Water
Quality. Temporary cofferdams and bypass piping will be utilized for stream management during the pipe
replacement. Upon project completion, the area impacted by the temporary cofferdam will be restored to
pre-project conditions.
The project is not located within '/2 mile of any critical watershed area; therefore, hazardous spill basins
are not required. Enclosed is the hazardous spill basin checklist. This office has conducted a GIS and
field survey for this project and is recommending a finding of "no effect" for T &E species and historical
structures. The proposed project is not located within any designated critical resources waters or NC-
designated waters or wetlands.
I have enclosed a pre-construction notification for a NW#14, sketches of planned activities, and location
maps relative to the project.
Project information for the 401 Automated Payment Procedure is as follows:
• Work order number: 150455-55120005-12.202321-3855
• TIP #: NA
• Project Category: $200.00 Fee
SR 1421
Page 2
2/20/06
If you have any questions or concerns, please feel free to contact me at (704) 480-9044. Thank you for
your time and consideration to this matter.
Respectfully yours,
M.L. Holder, P.E.
Division Engineer
Twelfth Division
BY:
Trish Simon
Division 12 Environmental Supervisor
Enclosures
Cc: Polly Lespinasse, DWQ, Mooresville Regional Office
Ron Linville, Wildlife Resources Commission (Courtesy Copy)
Office Use Only: Form Version Ma 2002
20060296
USACE Action ID No. DWQ No.
(If any particular item is not applicable to this project, please enter "Not Appucaote or NSA .)
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: NW 14.
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: Mike Holder N.C. Department of Transportation
Mailing Address: P.O. Box 47
Shelby North Carolina 28151
Telephone Number: 704-480-9020
E-mail Address:
Fax Number: 704-480-5401
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: N.C. Department of Transportation
Mailing Address: P.O. Box 47
Shelby North Carolina 28151
Telephone Number: 704-480-9044 Fax Number: 704-480-5401
E-mail Address: tsimon( dot state nc.us
Page I of 8
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: SR 1421, Mellon Road• Pipe replacement.
2. T.I.P. Project Number or State Project Number (NCDOT Only): 12.202311
3. Property Identification Number (Tax PIN): NA
4. Location
County: Cleveland Nearest Town: Lattimore
Subdivision name (include phase/lot number): NA
Directions to site (include road numbers, landmarks, etc.): SR 1351 from Lattimore;
left onto SR 1421 to project site.
5. Site coordinates, if available (UTM or Lat/Long): 35°20' 10"N/81°39'04"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. Property size (acres): <0.10 acre (NCDOT right of way).
7. Nearest body of water (stream/river/sound/ocean/lake): UT to Mayne Creek (East Fork
Sandy Run Creek) Class C waters (from source to Sandy Run Creek).
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/mgps/.)
9. Describe the existing conditions on the site and general land use in the vicinity of the
project at the time of this application: Existing Conditions -pipe on paved secondary
road. General Use- residential
Page 2 of 8
10. Describe the overall project in detail, including the type of equipment to be used:
Replacement of a 48", 50-ft pipe with a 60", 60-ft pipe with inlet headwall and
associated riprap for structure stabilization. Work will be done using a trackhoe.
11. Explain the purpose of the proposed work: The purpose of the proposed work is to
replace a failing pipe.
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. NA.
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 are anticipated for this project.
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 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 impacts from riprap
for structure stabilization.
2. Individuallv list wetland impacts below: NO WETLAND IMPACTS
Wetland Impact Area of Located within Distance to
Site Number Type of Impact 100-year Floodplain** Nearest Stream Type of Wetland***
indicate on ma Impact* acres es/no linear feet
Page 3 of 8
* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized
clearing, grading, fill, 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 (FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA
Map Service Center at 1-800-358-9616, or online at http://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.) 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: 0
Total area of wetland impact proposed: 0
3. Individually list all intermittent and perennial stream impacts below:
Stream Impact Site Length of Average Width of Perennial or
Number Type of Impact* Impact Stream Name** Stream Before Intermittent?
(indicate on map) (linear feet) Impact (please specify)
I Pipe length increase 10 feet UT to Mayne Creek 2 feet Intermittent
Riprap for structure
1 stabilization/Energy loft
"
dissipator at outlet
* 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.gov. 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:Permanent impacts =
20 ft.
4. Individually list all open water impacts (including lakes, ponds, estuaries, sounds,
Atlantic Ocean and any other water of the U.S.) below: 0
Open Water Impact
Site Number
indicate on ma
Type of Impact* Area of
Impact
acres
)
Name Waterbody
(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
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.
6. Pond Creation: NO POND IMPACTS
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.):_
Page 4 of 8
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 were minimized once the desired site plan was
developed. If applicable, discuss construction techniques to be followed during construction
to reduce impacts.
The failing pipe must be replaced for the safes of the travelling public. A slight increase in
pipe length is necessM to rebuild an adequate road shoulder. Minimal riprap is used for
structure stabilization.
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/strmgide.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,
Page 5 of 8
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.
MITIGATION NOT ANTICIPATED
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 (919) 733-5208 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/wrp/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):
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.
X.
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 (919) 733-5083 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 ?
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.
Page 6 of 8
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 ® 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
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.
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 213.0242 or.0260. NA
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.
There will be no increase in impervious acreage Appropriate erosion and sedimentation
control measures will be in place during the pipe replacement.
XII. 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.
NA
XIII. 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-fact permit application?
Yes ? No
Page 7 of 8
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).
NA
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Page 8 of 8
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Name: BOILING SPRINGS NORTH Location: 035° 20' 10.86" N 081- 39'04.52" W
Date: 2/20/2006 Caption: Pipe Replacement, SR 1421 (Mellon Road), LIT to Mayne Creek
Scale: 1 inch equals 1000 feet (East Fork Sandy Run Creek), Class C, Broad Basin
Upstream of Pipe Inlet
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NCDOT
HAZARDOUS SPILL BASIN CHECKLIST
Division: 1 ? County: Cleveland Project ID: 12.202311
River Basin: Broad Bridge No: Pipe Replacement
Route: SR 1421, Mellon Road Stream: _Unnamed Tributary to Ma}?ne
Creek Class C (From Source to Sandy Run Creek)
Water Quality Criteria:
Yes No
Stream Crossing Blue Line On USGS r w
ORW F W
WS1 r rw
WS 111,111 OR IV, Crossing Within 0.5mi of W.S. Critical Area r We
Roadway Criteria:
Route Designation-
Arterial Urban
Arterial Rural
Additional Site Information:
Is a Hazardous Spill Basin Required?
Yes No
r r
r r
Yes No
r r
Criteria Based Upon NCDOT "Best Management Practices for the
Protection of Surface Waters" (March, 1997).