20051246 Ver 1_Complete File_20050809

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Certificate of Completion
DWQ Project No.
Applicant:
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County:
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Project Name: S R Il9 Aa q wL I-2?0 a d
Date of Issuance of 401 Water Quality Certification: A ua uS O?`?
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
1, , 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: IV/• . Je` 0 Date: a _ 8 -o
Agent's Certification
1, , 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:
1, , 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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Mr. Mike Holder, P.E.
NCDOT Division 12
P.O. Box 47
Shelby, NC 28151
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek. P.E. Director
Division of Water Quality
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REISSUANCE/APPROVAL of 401 Water Quality Certification with Additional Conditions
Dear Mr. Holder:
August 9, 2005
DWQ# 05-1246
Gaston County
You have our approval, in accordance with the attached conditions and those listed below, to permanently
impact 20 linear feet (If) (10 If for pipe extension and 10 If for structure stabilization) and to temporarily impact
25 If (for temporary cofferdams) of an unnamed tributary* to Lick Fork Creek for the purpose of replacing a
deteriorating pipe, as described in your application received by the Division of Water Quality (DWQ) on July 12,
2005, and additional information received on July 26, 2005. This certification supercedes the Water
Quality Certification issued July 18, 2005, for this project. The location of the project is State Road 1642
(Requa Road) in Gaston County. After reviewing your application, we have determined that this project is
covered by Water Quality General Certification Number 3404. This certification corresponds to Nationwide
Permit 14 issued by the U.S. Army Corps of Engineers (USACE). 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
will expire with the associated 404 permit unless otherwise specified in the Water Quality Certification.
This approval is valid solely for the purpose and design that you described in your application (unless modified
below). 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 listed in the attached certification and those listed below:
Due to the presence of a concrete slab in the stream, DWQ will not require the burial of the culvert in the
streambed at this location. However, design and placement of the culvert and other structures, including any
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 below the location of the
culvert. The applicant may be required to provide evidence that the equilibrium has been maintained, if
requested in writing by the DWQ.
2. The riprap used to stabilize the area around the inlet and outlet must not interfere with thalweg performance
and aquatic life passage during low flow conditions.
*No stream determination performed.
North Carolina Division of Water Quality 610 East Center Avenue, Suite 301
Internet h2o.enr.state.nc.us Mooresville, NC 28115
Phone[phone]
Fax [phone]
K?` Carolina
,turally
An Equal Opportunity/Affirmative Action Employer- 50°/6 Recycled/109%o Post Consumer Paper
Page 2
3. 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 mainter
such BMP in order to protect surface water standards:
a. The design, installation, operation, and maintenance of the sediment and erosion control meas
must be such that they equal, or exceed, the requirements specified in the most recent versior
the North Carolina Sediment and Erosion Control Manual. The devices shall be maintained or
construction sites, borrow pit sites, and waste pile (spoil) projects, including contractor-owned
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 Su
Mining Manual.
c. The reclamation measures and implementation of these measures must be in accordance with
requirements of the Sedimentation Pollution Control Act.
4. Heavy equipment must be operated from the banks rather than in the stream channel, when possible,
order to minimize sedimentation and reduce the likelihood of introducing other pollutants into the strea
5. Temporary dewatering sites must be restored to pre-existing conditions unless more natural geomorpl
conditions can be provided.
6. No live or fresh concrete shall come into contact with waters of the state until the concrete has harden
7. The dimension, pattern and profile of the stream above and below the crossing should not be modifiec
Disturbed floodplains and streams should be restored to natural geomorphic conditions.
8. All mechanized equipment operated near surface waters must be regularly inspected and maintained
prevent contamination of stream waters from fuels, lubricants, hydraulic fluids, or other toxic materials
9. All work shall be performed during low or normal flow conditions.
10. Discharging hydroseed mixtures and washing out hydroseeders and other equipment in or adjacent tc
surface waters is prohibited.
11. Sediment and erosion control measures shall not be placed in wetlands or waters to the maximum exl
practicable. If placement of sediment and erosion control devices in wetlands and waters is unavoida
they shall be removed and the natural grade restored within 30 days after the Division of Land Resoui
released the project.
12. The North Carolina Department of Transportation (NCDOT) and its contractors and/or agents shall no
excavate, fill or perform mechanized land clearing at any time in the construction or maintenance of th
project within waters and/or wetlands, except as authorized by this Certification, or any modification tc
Certification (e.g., no work shall occur outside of the footprint of the plans provided). In addition, there
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 requirec
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.
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,
for Alan W. Klimek, P.E.
Attachments
cc: Steve Lund, USACE Asheville Field Office
Rob Ridings, DWQ Wetlands Unit
Central Files
File Copy
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Mr. Mike Holder, P.E.
NCDOT Division 12
P.O. Box 47
Shelby, NC 28151
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
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APPROVAL of 401 Water Quality Certification with Additional Conditions
Dear Mr. Holder:
July 18, 2005
DWQ# 05-1246
Gaston County
You have our approval, in accordance with the attached conditions and those listed below, to permanently
impact 20 linear feet (10 (10 If for pipe extension and 10 If for structure stabilization) and to temporarily impact
25 If (for temporary cofferdams) of an unnamed tributary* to Lick Fork Creek for the purpose of replacing a
deteriorating pipe, as described in your application received by the Division of Water Quality (DWQ) on July 12,
2005. The location of the project is State Road 1642 (Requa Road) in Gaston County. After reviewing your
application, we have determined that this project is covered by Water Quality General Certification Number
3404. This certification corresponds to Nationwide Permit 14 issued by the U.S. Army Corps of Engineers
(USACE). 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 will expire with the associated 404 permit unless
otherwise specified in the Water Quality Certification.
This approval is valid solely for the purpose and design that you described in your application (unless modified
below). 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 listed in the attached certification and those listed below:
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
below locations of each culvert. The applicant may be required to provide evidence that the equilibrium has
been maintained, if requested in writing by the DWQ.
2. The riprap used to stabilize the area around the inlet and outlet must not interfere with thalweg performance
and aquatic life passage during low flow conditions.
'No stream determination performed.
North Carolina Division of Water Quality 610 East Center Avenue, Suite 301
Internet: h2o.enr.state.ne.us Mooresville, NC 28115
Phone [phone]
Fax [phone]
Norc hCarolina
Naturallil
An Equal Opportunity/Affirmative Action Employer-50% Recycled/10% Post Consumer Paper
Page 2
3. 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
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.
4. 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.
5. Temporary dewatering sites must be restored to pre-existing conditions unless more natural geomorphic
conditions can be provided.
6. No live or fresh concrete shall come into contact with waters of the state until the concrete has hardened.
7. 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.
8. 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.
9. All work shall be performed during low or normal flow conditions.
10. Discharging hydroseed mixtures and washing out hydroseeders and other equipment in or adjacent to
surface waters is prohibited.
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 h
released the project.
12. The North Carolina Department of Transportation (NCDOT) and its contractors and/or agents shall not
excavate, fill or perform mechanized land clearing at any time in the construction or maintenance of this
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 sincf
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. Pleas
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 21-1.0503, 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,
for Alan W. Klimek, P.E.
Attachments
cc: Steve Lund, USACE Asheville Field Office
Rob Ridings, DWQ Wetlands Unit
Central Files
File Copy

051246
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STATE of NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY DIVISION OF HIGHWAYS LYNDO TIPPEIT
GOVERNOR SECRETARY
July 5, 2005
Mr. Steve Lund - NCDOT Projects P
US Army Corp of Engineers J U L 1 2 2005
Asheville Regulatory Field Office
151 Patton Avenue, Room 208 DENk - WATER QUAD l )
Asheville, N. C. 28801-5006 WEri A Jn ,?u rrn+Kowr F r, tNCH
SUBJECT: Pipe replacement, SR 1642 (Requa Road), Gaston County
Dear Mr. Lund:
The North Carolina Department of Transportation proposes to replace a deteriorating pipe on SR 1642
(Requa Road) in northeastern Gaston County. An existing 30-foot long, 72" CMP will be replaced with
a 40-foot long, 72" CMP with inlet and outlet concrete headwall. Ten feet of riprap will be utilized at the
pipe inlet and outlet for structure stabilization. Coconut fiber matting will be utilized, as needed, for bank
stabilization above the average high water level.
A concrete slab retaining wall is located on the left downstream bank. A section of concrete slab is also
located in the streambed. A small portion of the concrete slab in the streambed and the retaining wall will
be removed for the pipe replacement; however, most of the concrete will remain -at the adjacent property
owner's request.
Temporary cofferdams and bypass pumping will be used for stream management during construction.
The scope of the work will result in a 10 feet of pipe fill impacts, 10 feet of riprap impacts from structure
stabilization, and 25 feet of temporary impacts to an unnamed tributary to Lick Fork Creek, which is
classified as a WS-IV watershed by the Division of Water Quality.
The proposed project is not located within '/z mile of the critical watershed area, nor is SR 1642 a rural or
urban arterial. Hazardous spill basins are not required. Enclosed is the NCDOT 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..
I have enclosed a PCN application for a NW #14 for permanent fill impacts associated with linear
transportation crossings, sketches of planned activities, photographs documenting existing conditions, and
location maps relative to the project.

SR 1642, Requa Road
Page 2
7/5/05
If you have any questions or concerns, please feel free to contact me at [phone]. 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: John Hennessy, DWQ/401/Transportation Permitting Unit
Polly Lespinasse, DWQ, Mooresville Regional Office
Ron Linville, Wildlife Resources Commission (Courtesy Copy)
Office Use Only: Form Version May 2002
_2005124e
USACE Action ID No. DWQ No.
(If anv particular item is not applicable to this project, please enter "Not Applicable" or "N/A".)
L 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..
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: ?
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (verify availability with NCWRP prior to submittal of PCN), complete
section VIII and check here: ?
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: ?
H. 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: 704480-9020 Fax Number: 704-480-5401
E-mail Address:
2. Agent Information (A signed and dated copy of the Agent Authorization letter must be
attached if the Agent has signatory authority for the owner/applicant. )
Name: Trish Simon
Company Affiliation: 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 e,dot.state.nc.us
Page 1 of 9
HL 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 1642„ CKNua Road) Pipe replacement
2. T.I.P. Project Number or tag Project Number (NCDOT Only): 12B.203621
3. Property Identification Number (Tax PIN): NA
4. Location
County: Cleveland Nearest Town: Chegyville
Subdivision name (include phasellot number): NA
Directions to site (include road numbers, landmarks, etc.):H vy 274 north from Cherrwille.
Turn right onto SR 1638, turn right onto SR 1642 to site.
5. Site coordinates, if available (UTM or Lat/Long): 35°24'55"N/81°22'47"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): 0.20 acre (NCDOT right of way)..
7. Nearest body of water (stream/river/sound/ocean/lake): Unnamed tributary to Lick Fork
CreeL (from source to Indian Creek). WS-IV Watershed.
8. River Basin: Catawba
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/maps/.)
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 unpaved secondary road. General
Land Use- wooded, residential.
Page 2 of 9
10. Describe the overall project in detail, including the type of equipment to be used: Replacement
of a deteriorating, 30-foot. 72" CW with a new 40-foot. 72" CMP with inlet and outlet
concrete headwalls Five feet of riprap will be utilized on the banks at the inlet and outlet 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 deteriorating 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 at this site are anticipated
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 minimal
increase in pipe length and associated riprap for structure stabilization
2. Individually list wetland impacts below: NO WETLAND IMPACTS
Wetland Impact
Type Area of Located within Distance to
***
Site Number pactt* Impact
I 100 year Floodplain** Nearest Stream Type of Wetland
indicate on ma (acres) es/no linear feet

Page 3 of 9
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
stricture and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance
Rate Maps (MIA), or FEMA-approved local floodplam maps. Maps are available through the FEMA Map Service
Center at 1-800-358-9616, or online at http://www.fcma.aov.
*** 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 Length of Perennial or
Site Number Type of Impact* Impact Stream Name** Average Width of Intermittent?
(indicate on (linear feet) Stream Before (please specify)
ma Impact
1 Pipe replacement 10 feet UT to Lick Fork 3.5 feet Perennial
Creek
Riprap for structure 5 feet (inlet)
1 stabilization 5 feet (outlet) "
10 feet (total)
Temporary
1 Cofferdams 25 feet "
List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated
rip-rap, dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after,
and net loss/gam), 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.mapguest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site:Permanent fill impacts = 10
ft; Permanent Streambank Impacts = 10 feet; Temporary Cofferdam Impacts = 25 feet.
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 hnpact Area of
Name Wate Type of Waterbody
Site Number Type of Impact* Impact )
(? applicable) (lake, pond, estuary, sound,
indicate on ma acres bay, ocean, etc.

• List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation,
dredging, flooding, drainage, bulkheads, etc.
Page 4 of 9
5. 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 a plication.
Pond to be created in (check all that apply): ? uplands [j stream ? wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.):_
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.):_
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
There is a minimal increase in pipe length to provide for an adequate road shoulder for safety
purposes.
VUL 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.
Page 5 of 9
Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
Coconut fiber matting will be utilized above the average high water mark for bank
stabilization.
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP). Please note it is the applicant's responsibility to contact the NCWRP at
[phone] to determine availability and to request written approval of mitigation prior
to submittal of a PCN. For additional information regarding the application process for the
NCWRP, check the NCWRP website at http://h2o.enr.state.nc.us/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. Environmental Documentation (required by DWQ)
Does the project involve an expenditure of public (federal/state) funds or the use of public
(federal/state) land?
Yes ® No ?
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ? No
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes ? No ?
X. Proposed Impacts on Riparian and Watershed Buffers (required by DWQ)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Page 6 of 9
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes ? No ® If you answered "yes", provide the following information:
Identify the square feet and acreage of impact to each zone of the riparian buffers,
mitigation is required calculate the required amount of mitigation by applying
multipliers.
*
Zone Impact
(square feet
Multiplier Required
Mitigation
1 3
2 1.5
Total
* Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
If buffer
the buffer
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B.0242 or.0260. NA
XL 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 a minimal increase in impervious acreage due to a slight increase in the road
shoulder width. AD= 16 a 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
XM. Violations (required by DWQ)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit application?
Yes ? No
Page 7 of 9
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).
I"/,/- ? .? 5 -C)5
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Page 8 of 9
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NCDOT
HAZARDOUS SPILL BASIN CHECKLIST
Division: L2- County: -Project ID: p;?'Rco1T
River Basin: CcrApw ba Bridge No: N/ A
Route: ltp42 Stream: L Ior4w ex4 7'r%\Jar" 4o UcK FoeY GrY-
Water Quality Criteria:
Yes No
Stream Crossing Blue Line On USGS rr---' r
ORW C r?
WSI C F-
WS H,I1I OR IV, Crossing Within 0.5mi of W.S. Critical Area F r?
Roadway Criteria:
Route Designation-
Yes No
Arterial Urban F r-
Arterial Rural F F-
Additional Site Information:
Yes No
Is a Hazardous Spill Basin Required?
r- r--
Criteria Based Upon NCDOT "Best Management Practices for the
Protection of Surface Waters" (March, 1997).
ed °?
'! a.. d'
Vi@R5W195
JUL 1 2 2005
DENR • WATER QUALITY
WETLANDS AND STORMWATER BRANCH
STATE or NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
MICHAEL F. EASLEY LYNDO TIPPETT
GOVERNOR SECRE'rARY
051~46
MEMO TO: John Hennessy, DENR/DWQ/401/Transportation Permitting Unit
FROM: Trish Simon, Division 12 Environmental Supervisor f5
DATE: July 5, 2005
SUBJECT: Pre-Construction Notification/401 Automated Payment
Enclosed are seven copies of a pre-construction notification for a NCDOT project in Gaston County for
your review.
Project information for the 401 Automated Payment Procedure is as follows:
• Work order number: 150464-55120005-12B.203621-3855
• TIP #: NA
• Project Category $200.00 Fee
is
CK NO.
Post Office Box 47 Shelby, North Carolina 28151-0047