20110101 Ver 1_Information Letter_20110406

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STATE OF NORTH CAROLINA B
DEPARTMENT OF TRANSPORTAT1bk*4,,?1??% CJJ
BsvEx[ r EAVES PERDUE EU ry . Corrr[, JR.
GOVERNOR Se OARY
March 30, 2011
NC Division of Water Quality
1650 Mail Service Center
Raleigh, NC 27699-1650
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Attention: Ms. Coleen H. Sullins
Director
Subject: B-4413 Response to NC Division of Water Quality (NCDWQ) Letter
Reference: Permit Application for B-4413 dated January 21, 2011
Dear Madam:
This letter addresses items from NCDWQ's March 17, 2011 letter regarding the proposed
replacement of bridge No. 51 over Broad Creek in Beaufort County. A copy of this letter
has been provided for your convenience.
1) PCN - a signed copy has been included in this response. Please note, as indicated in
the permit application cover letter, all PERMIT APPLICATIONS and ISSUED PERMITS
are available on the following NCDOT website (below). Although the PCN was
inadvertently omitted from DWQ's hard copy, it has been available on the website
since the January 2011 posting.
http•//www.ncdot.org/doh/preconstruct/pe/neu/Permit.html
2) Stormwater Management Plan - NEU staff has worked with the NCDOT Hydraulics
Unit to provide elaboration to the tabular Stormwater Management Plan (SMP
attached). Clarifying information is provided within the "General Comments"
section on page 1 of 2. Additional information and data regarding the specific
Stormwater Control Measures (SCM) utilized for this project are provided on page
2 of 2 of the SMP.
3) Impact Justification -The NCDOT proposes utilizing embankments with Class I rip-
rap to connect the proposed grassed swales (between US 264 and the relocated
driveways) to Broad Creek. This measure is recommended to minimize potential
MAILING ADDRESS: - TELEPHONE: [phone] LOCATION:
NC DEPARTMENT OF TRANSPORTATION FAX: [phone]
PROJECT DEVELOPMENT AND ENVIRONMENTAL ANALYSIS 1020 BIRCH RIDGE DRIVE
1598 MAIL SERVICE CENTER WEBSITE. YW1 W NCDOT.ORG RALEIGH NC 27610-4328
RALEIGH NC 27699-1598
bank erosion in the transitional area to the creek. Without rip rap in this location
there is potential for bank erosion during a rain event in low flow conditions.
The rip-rap does not extend into the creek channel but will be inset into the bank
(approximately 1 foot) and will run from the terminus of the grassed Swale, down
along the bank slope, and will be terminated at the toe of slope of the channel.
The width of these structures will be approximately 5'- 6' and the length of the
structures from below the plane of the ordinary high water mark to the toe of bank
will be approximately 14.4' for the structure on the north bank and 8' for the
structure on the south bank. Given these dimensions, the amount of rip-rap used
will be approximately 0.25 cubic yard per one foot as measured into the channel
(perpendicular to flow) or approximately 0.8 cubic yard per one foot as measured
p
UIdr}gtbe cchjn?el.
These structures have been permitted under a NWP 13 (Action ID: SAW-2011-
00308) as issued February 08, 2011 by the Wilmington District of the US Army
Corps of Engineers (USACE). These structures adhere to the specific conditions as
stipulated under this permit, including but not limited to, a) No material is placed in
excess of the minimum needed for erosion protection, and c) The activity will not
exceed an average of one cubic yard per running foot placed along the bank below
the plane of the ordinary high water mark or the high tide line, unless this criterion
is waived in writing by the district engineer. Additionally, these structures adhere
to the Regional Conditions for Nationwide Permits in the Wilmington District
including but not limited to Sections 3.5 Requirements for Using Riprap for Bank
Stabilization, and 4.0 Additional Regional Conditions Applicable to Specific
Nationwide Permits. Reduction or elimination of these rip rap embankments is not
recommended.
We hope that these responses adequately address your concerns. If additional
information or clarification is needed in the future, please notify our staff as soon as
possible to avoid delays.
If you have additional questions, please contact Lance P. Fontaine, Ph.D. at 919-707-6118
or Ipfontaine@ncdot.¢ov.
Thank you,
\"" Gregory J. Thorpe, Ph.D., Manager
Project Development & Environmental Analysis Branch
cc: w/ attachments
Mr. Tom Steffens, USACE
Mr. Garcy Ward, NCDWQ
Ms. Sonia Carrillo, NCDWQ, 401 Wetlands Unit
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NC®ENR
North Carolina Department of Environment and Natural
Division of Water Quality
Beverly Eaves Perclue
rector
Ctleen H. Sullins
A 4- 9 g y D
-ate Y Y ?KE
Resources
MAR 24 20111
Dee Fri` aSec el 1 IGi'f 'OF HIGHWAYS
March 17, 2011
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
70100290 0001 5628 9981 .
Dr. Greg Thorpe, PhD., Manager
Project Development and Environmental Analysis
North Carolina Department of Transportation
1548 Mail Service Center
Raleigh, North Carolina, 27699-1548
Subject: Replacement of Bridge No. 51 over Broad Creek in Beaufort County, B-4413
Dear Dr. Thorpe:
The NC Division of Water Quality has reviewed your submittal for a 401 Water Quality Certification and
Tar-Pamlico Buffer Authorization for the aforementioned project. Review of your application revealed it
lacking necessary information required for making an informed permit decision. The permit application
was deficient in the following areas:
PCN
A Pre-Construction Notification (PCN) form was not included in the application. Please
submit a completed PCN form.
2. Stormwater Management Plan.
Please include a proper Stormwater Management Plan as required in Section E(2) of the PCN
form.
3. Impact Justification.
Please explain the need for the extensive embankment rip-rap as shown on the upstream side
of the bridge (STA. 13+50 -L- TO STA. 15+42 -L- LT and STA. 16+16 -L- TO STA.
17+00 -1: LT) and whether it is possible for this to be eliminated or reduced.
Tl erer'.e ._ ,.,......t tn.l e, A Ni.A C '14 ,nSM(a}we will have. tn,place the Permit apnlication,on hold;,.,
1'. 2
until we are supplied the necessary information l tia 1 avc 21 days to restond in w iting wit:; the
requested information or notification to this office that the information is forthcoming. If, at the end of
the 21 days, this office has not received this information in writing, we will assume you are withdrawing
your application and it will be returned. Furthermore, until the information is received by the NC
Division of Water Quality, we request (by copy of this letter) that the US Army Corps of Engineers place
the permit application on hold.
North Carolina Division of Water Quality Internet }??s1:St5Ni?t30.t!?h[Y?" One
943 Washington Square Mall Phone: [phone] NorthCarohna
Washington. NC 27899 FAX 252 x)46-9115 ./V17tUPO11I/
Page 2 of 2
if you have any questions or require additional information, please contact Garcy Ward at (252) 948-
3922.
Sincerely,
Coleen H. Sullins
Director
cc: Tom Steffens, US Army Corps of Engineers, Washington Field Office
Sonia Carrillo, DWO_. 401 Wetlands Unit
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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 E] Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: 23 13 or General Permit (GP) number:
1c. Has the N WP or GP number been verified by the Corps? ? Yes ®No
1d. 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
If. 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 In
below. ® Yes ? No
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ® Yes ? No
2. Project Information
2a. Name of project: Replacement of Bridge No. 51 over Broad Creek on US 264
2b. County: Beaufort
2c. Nearest municipality / town: Pantego
2d. Subdivision name: not applicable
2e. NCDOT only, T.I.P. or state
project no: B-4413
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 i f
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]
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
1 a. Property identification no. (tax PIN or parcel ID): not applicable
1b. Site coordinates (in decimal degrees): Latitude: 35.570604 Longitude: - 76.692861
(DD.DDDDDD) (-DD.DDDDDD)
1c. Property size: 2.7 acres
2. Surface Waters -
2a. Name of nearest body of water (stream, river, etc.) to Broad Creek
proposed project:
2b. Water Quality Classification of nearest receiving water: SC, NSW
2c. River basin: Tar Pamlico
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:
Existing conditions on the site include mostly forested areas with maintained/disturbed roadside shoulders and driveway
access to Broad Creek. General land use in the project vicinity is agriculture and silviculture.
3b. List the total estimated acreage of all existing wetlands on the property:
0.85
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
Broad Creek - 512 feet
3d. Explain the purpose of the proposed project:
To 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 69-foot bridge with a 130-foot, 3-span bridge on the existing alignment with an off-site
detour. Standard road and bridge building equipment, such as trucks, dozers, and cranes will be used. Telephone and
fiber-optic utilities will be relocated on-site via the directional bore method without impacts to wetland areas or Broad
Creek.
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:
4b. 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: ESI, Inc.
Name (if known): J. Harbour Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
October 6, 2009
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.
A representative for Tideland EMC contacted our office on November 05, 2009 indicating that the utility company would
be relocating their existing pole line and would acquire the necessary permits.
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
Site 1 ® P ? T Fill Riparian El Nos ? DCorps WQ 0.33
Site 2 ® P ? T Excavation Riparian ® Yes
? No ® Corps
? DWQ 0.01

Site 3 ®P ? T Mechanized
clearing
Riparian ® Yes
? No ® Corps
? DWQ
0.24
? Yes ? Corps
Site 4 ? P ? T ? No ? DWQ
? Yes ? Corps
Site 5 ? P ? T ? No ? DWQ
? Yes ? Corps
Site 6 ? P ? T ? No ? DWQ
2g. Total wetland impacts 0.58 Permanent
0.00 Temporary
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 M (INT)? DWQ - non-404, (feet)
other)
Site 1 ® P ? T Embankment
Riprap Broad Creek ® PER
? INT ® Corps
? DWQ 70 11

Site 2 ? P ® T Existing
abutment
Broad Creek ® PER
? INT ® Corps
? DWQ
70
58
removal
? PER ? Corps
Site 3 El P ? T ? INT ? DWQ
? PER ? Corps
Site 4 ? P ? T ? INT ? DWQ
- El PER El Corps
1 P ? T
Site 5 [ ? INT ? DWQ
? PER ? Corps
Site 6 ? P ? T ? INT ? DWQ
3h. Total stream and tributary impacts 11 Perm
58 Temp
3i. Comments: Impacts due to proposed piers is 20 square feet (<0.01 ac).
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. 4b. 4c. 4d. 4e.
Open water Name of
impact number - waterbody Type of impact Waterbody type Area of impact (acres)
Permanent (P) or (if applicable)
Temporary
01 ?P?T
02 ?P?T
03 ?P?T
04 ?P?T
4f. Total open water impacts
F X Permanent
X Temporary
4g. Comments:
5. Pond or Lake Construction
If and or lake construction proposed , then complete the chart below.
5a. 5b. 5c. 5d. 5e.
Wetland Impacts (acres) Stream Impacts (feet) Upland
Pond ID Proposed use or (acres)
number purpose of pond Excavat
Flooded Filled ed Flooded Filled Excavated Flooded
P1
P2
5f. Total
5g. Comments:
5h. Is a dam high hazard permit required?
? Yes ? No if yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
6
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 mitigation, then you MUST fill out Section D of this form.
6a.
? Neuse ®Tar-Pam lico ? 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 required?
s
131 ®P ? T Roadway Fill Broad Creek ® No 218 809
s
B2 ® P ? T Bridge Broad Creek ® No 927 0
s
®
B3 ®P ? T Driveway Broad Creek ? No 1130 782
s
B4 ®P ? T Access Road Broad Creek ® No 2225 1367
6h. Total buffer impacts 4500 2958
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 bridge is 61 feet longer than the existing bridge; the proposed bridge will be at approximately the same
grade as the existing structure; an off-site detour will be used; development and adherence to stormwater management
plan involving the use of grassy swales where appropriate, reduction in bent quantity (from 5 to 2), use of class I rip rap to
prevent erosion at outlets, no deck drains, and use of preformed scour holes. Additionally, hydrological connectivity of the
stream will be improved with the use of a longer bridge and removal of fill to improve hydrological conveyance and reduce
velocities; an off site detour will be used, 3:1 fill slopes where practicable.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Design Standards in Sensitive Watersheds utilizing appropriate sedimentation and erosion control measures; top-down
construction; adherence to in-water work moratorium of February 15 to June 15 due to anadromous fish; adherence to
West Indian Manatee Guidelines; telephone and fiber optic utilities will use trenchless method (directional bore) to place
their facilities under Broad Creek; staging area and access boxes for telephone and fiber optic utilities will be located
outside wetland areas and buffer zone.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for ® Yes ? No
impacts to Waters of the U.S. or Waters of the State?
If no, explain:
2b. If yes, mitigation is required by (check all that apply): ? DWQ ® Corps
? Mitigation bank
2c. If yes, which mitigat ion option will be used for this ® Payment to in-lieu fee program
project?
? 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: 0 linear feet
4c. If using stream mitigation, stream temperature: ? warm ? cool ?cold
4d. Buffer mitigation requested (DWQ only): BZ1: 3,390; BZ2: 1,173 square feet
4e. Riparian wetland mitigation requested: 1.16 acres
4f. Non-riparian wetland mitigation requested: 0 acres
4g. Coastal (tidal) wetland mitigation requested: 0 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 ® Yes ? No
. buffer mitigation?
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.
6c. 6d. 6e.
Zone Reason for impact Total impact Multiplier Required mitigation
(square feet) (square feet)
Zone 1 Fill for driveway 1,130 3 (2 for Catawba) 3,390
Zone 2 Fill for driveway 782 1.5 1,173
6f. Total buffer mitigation required: 4,563
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).
NC EEP will provide buffer mitigation.
6h. Comments: Required mitigation for impacts in buffer that are not associated with bridge or canal maintenance access
road.
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers identified ® Yes ? No
within one of the NC Riparian Buffer Protection Rules?
1b. If yes, then is a diffuse flow plan included? If no, explain why.
®Yes ? No
Comments: See attached permit drawings.
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, narrative description of the plan:
See attached permit drawings and stormwater management plan.
? 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 It
3b. Which of the following locally-implemented stormwater management programs ? NSW
? 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
attached? ? Yes ® No
5. DWQ 401 Unit Stormwater Review
5a . Does the Stormwater Management Plan meet the appropriate requirements? ? Yes ? No NA
5b . Have all of the 401 Unit submittal requirements been met? ? Yes ? No NA
10
F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1a. 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 th a above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
® Yes ? No
letter.)
Comments:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0 500), Isolated
Wetland 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
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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
®
Sc. If yes, ind icate the USFWS Field Office you have contacted.
? Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
NCNHP, USFWS, field surveys; Re-survey for sensitive joint-vetch conducted June 25, 2009. Biological conclusion
remains No Effect.
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

?
i _
?U 3 2q.
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Dr. Gregory J. Thorpe, PhD ,
' 4 D
s Printed Name
ApplicanUAgent Ap licant/A ent's Signature • ate
(Agent's signature is valid only if an authorization letter from the applicant
is provided.)
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