20110924 Ver 1_Application_20111018

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10924
Office Use Only:
Corps action ID no.
DWQ project no.
Farm Version 1.3 Dec 10 2008
Pr e-Construction Notification PC Form
A. Applicant Information
1. Processing
I a. Type(s) of approval sought fro
Corps: non-reporting the I
®Saction 404 Permit ? Section 10 Permit
1b. Specify Nationwide Permit (NM ) number. NWP 3 and 13 or General Permit (GP) number:
1c. Has the NWP or GP number be en verified by the Corps? ? Yes ® No
1d. Type(s) of approval sought from
® 401 Water Quality Certificati

? 401 Water Quality Certificati the DWQ (check all that apply):
on - Regular ? Non-404 Jurisdictional General Permit
r
on -Express ? Riparian Buffer Authorization
le. Is this'not'fiication solely for the
because written approval is not record
required? For the record only for DWQ 401
Certifi
Ye ? No For the record only for Corps Permit:
I
oyes ? No
If. Is payment into a mitigation bar
of impacts? If so, attach the ac
fee program. k or in-lieu fee program proposed for mitigation
ceptance letter from mitigation bank or in-lieu ? Yes ® No
1g. Is the project located in any of
below. C's twenty coastal counties. If yes, answer lh ? Yes ® No
1 h. Is the project located within a N DCM Area of Environmental Concern (AEC)? ? Yes ®No
2. Project Information
2a. Name of project: Proposed repair of a cross line conveying Lynch Creek on SR 1548 (Peter Gill Road)
2b. County: Vance
2c. Nearest municipality / town: Henderson
2d. Subdivision name: N/A
2e. NCDOT only, T.I.P. or state
project no:
3. Owner Information or 71,
3a. Name(s) on Recorded Deed: NCDOT Division 5 8
3b. Deed Book and Page No. N/A S qt 8q Fq
3c. Responsible Party (for LLC if
applicable): UWq iry
N/A TEq
3d. Street address: 2612 N. Duke Street
3e. City, state, zip: Durham, NC 27704
3f. Telephone no.: [phone]
3g. Fax no.: [phone]
3h. Email address: wbowman(dincdot.aov
4. Applicant Information (if diffe ent from owner) N/A
5. Agent/Consultant Information (If applicable) N/A
Page 1 of 8 ,
PCN Form -Version 1.3 December 10, 2008 Version
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B. Project Information and Pri or Project History
1. Property Identification
I a. Property identification no. (tax IN or parcel ID): N/A
1b. Coordinates (in decimal degref s):
Site: Latitude:36.26538 I Longitude: -78.40269
(DD.DDODDD) (-DD. DDDDDD)
1c. Property size: < 0.01 acres
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2 Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to

proposed project: Lynch Creek
2b. Water Quality Classification of nearest receiving water. C NSW
2c. River basin: Tar-Pamlico
3. Project Description
38. Describe the existing condition on the site and the general land use in the vicinity of the project at the time of this
application:
The existing structure has sepa rated end joints to the inlet and outlet ends. The associated shoulder and fill slopes have
failed. Site is surrounded by wo oded and commercial lands.
3b. List the total estimated acreage of all existing wetlands on the property:
NONE
3c. List the total estimated linear fee t of all existing streams (intermittent and perennial) on the property:
60 It
3d. Explain the purpose of the posed project: The pipe repair will allow for an adequate and more stable shoulder
sections and fill slopes at this sling.
3e. Describe the overall project In tail, including the type of equipment to be used:
Separated end joints will be re at both the inlet and outlet of this structure. The area will then be beck filled to provide
an adequate slope section. Ri rap will be installed underlined with filter fabric for lorig tern stability surrounding the pipe
ends. E ui ment may include backhoe an excavator, and grader.
4. Jurisdictional Determination
4a. Have jurisdictional wetland or ream determinations by the
Corps or State been requested
project (including all prior ph r obtained for this property /
s) in the past?
? Yes ® No; ? Unknown
Comments: N/A
4b. If the Corps made the jurisdicti net determination, what type
? Preliminary ? Final
of determination was made?
4c. If yes, who delineated the jurisd ctional areas? Agency/Consultant c?mpany: N/A
Name (if known): WA Other: N/A
4d. If yes, list the dates of the Corp jurisdictional determinations or State determinations and attach documentation.
WA
6. Project History
5a. Have permits or certifications be
this project (including all prior an requested or obtained for
ases) in the past? Yes ®No ? Unknown
5b. If yes, explain in detail acoordin to 'help file' instructions.
WA
I,
Page 2 of 8
PCN Form - Version 1.3 December 10, 2008 Version
6. Future Project Plans
6a. Is this a phased project? ? Yes ® No
6b. If yes, explain.
i
N/A
C. Proposed Impacts inventor
1. Impacts Summary
Is. Which sections were completed below for your project (check all that apply):
? Wetlands ® Strea is - tributaries ? Buffers
? Open Waters ? Pond Construction
2. Wetland Impacts
If there are wetland impacts propo 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 i act Type of wetland Forested (Corps - 404, 10 Area of impact
Permanent (P) or (if known) DWO -;non-404, other) (acres)
Temporary
W1 ? P ? T WA N/A ? Yes
? No ? Corps,
? DWQ ' WA
2g. Total Wetland Impacts: NONE
2h. Comments: WA
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 impacte d.
3a. 3b. 3c. 3d. 3e. 3f. 3g.
Stream impact Type of imp kct Stream name Perennial Type of jurisdiction Average Impact
number - (PER) or (Corps! 404, 10 stream length
Permanent (P) or intermittent DWO -non-404, width (linear
Temporary M (INT)? other) (feet) feet)
Site 1 ® P ? T
Stream 1 rip rep UT Lynch Creek ® PER
? INT ® Corps:
® DWQ 2 10
Site 1 ? P ® T dewatedri UT Lynch Creek ® PER ® Corps' 2 35
Stream 1 ? INT ® DWQ i - L
3h. Total stream and tributary Impacts 35
3i. Comments: rip rap will be placed on banks (up to 5ft upstream and downstream), not within the flow line
4. Open Water Impacts
If there are proposed impacts to lak is, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then Individual list all ope n water impacts below.
4s. 4b. 4c. 4d. 4e.
Open water impact Name of wat body
number - (if applica e) Type of impact Waterbgdy type Area of impact (acres)
Permanent (P) or
Temporary
Ot ? P ? T WA N/A WA WA
4f. Total open water Impacts NONE
4g. Comments: WA

Page 3 of 8
PCN Form -Version 1.3 December 10, 2008 Version
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5. Pond or lake Construction
If and or lake construction ro d, then complete the chart below.
5a. 5b. 5c. 5d. 5e.

Pond ID
Proposed use or purp
ose of Wetland Impacts (acres) Stream Impacts (feet) Upland

number (acres)
pond
Flooded Filled Excavated Flooded : Filled Excavated Flooded
P1 N/A WA WA WA WA i N/A WA WA
P2
5f. otal NONE NONE NONE NONE NONE NONE NONE
5g. Comments: WA
5h. Is a dam high hazard permit rec uired?
? Yes ® No If yes, permit ID no: N/A
Si. Expected pond surface area (a ): WA
5j. Size of pond watershed (acres N/A
5k. Method of construction: WA
6. Buffer Impacts (for DWG)
If project will impact a protected ripa rian buffer, then complete the chart below. If yes, than individually list all buffer impacts
below. If an impacts require iti 'on, then ou MUST fill out Section D of this form.
6a.
® Nauss ? Tar-Pamlico ? Other.
Project is in which protected basin? ? Catawba ? Randleman
6b. 6c. 6d. 6e. 6f. 69.
Buffer impact
number - Reason for Buffer Zone l impact Zone 2 impact
Permanent (P) or impact Stream name mitigation (square feet) (square feet)
Temporary required?
Site ? P ? T ? Yes

Buffer Impact 1 WA WA
? No N(A WA

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6h. Total buffer Impacts WA WA
6i. Comments: project site is within ar-Pamlico, but work to be done within existing transportation facility.
D. Impact Justification and MItIga tion
1. Avoidance and Minimization
la. Specifically describe mess res taken to avoid or minimize the proposed impacts in designing project

The impacts to the stream are mini .
at and to maintain a dry work area if necessary and to armor the repaired pipe ends. This
repair cannot be performed without tream impacts.
1b. Specifically describe mess res taken to avoid or minimize the proposed impacts through constriction techniques.
Sediment and erosion control Best anagement Practices for protection of surface waters and riparian buffers will be
enforced during project construction
I
Version 1.3 December 10, 2008 Version
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Cam
impacts to Waters of the U.S. o nsatory Mitigation for
r Waters of the State? ? Yes ® No

2b. If yes, mitigation is required
by (check all that apply): i
? DWQ ? Corps,

2c. If yes, which mitigation option w
ill be used for this project? ? Mitigation bank
[I Payment to in-lieu fee program
i
? Permittee Responsible Mitigation
3. Complete H Using a Mitigatio n Bank
3a. Name of Mitigation Bank: WA
3b. Credits Purchased (attach racer t and letter) Type WA Quantity WA
3c. Comments: N/A
4. Compote M Making a Paymen t to Inaleu Fee Program
4a. Approval letter from in4ieu fee p rogram is attached. ? Yes
4b. Stream mitigation requested: WA linear feet
4c. If using stream mitigation, strea temperature: ? warm ? cool ?cold
4d. Buffer mitigation requested (D Q only): WA square feet,
4e. Riparian wetland mitigation req ed: N/A acres
4f. Non-riparian wetland mitigation uealed: N/A acres
4g. Coastal (tidal) wetland mitigati requested: N/A acres
4h. Comments: WA
6. Complete If Using a Permttlee Responsible Mitigation Plan
Sa. If using a permitiee responsible
NIA mitigation plan, provide a description of the proposed mitigation plan.
6. Buffer Mitigation (State Regu ated Riparian Buffer Rules) -required by DWQ
i
6a. Will the project result in an impa
buffer mitigation? ct within a protected riparian buffer that requires ? Yes ® No
6b. If yes, then Identify the square f
amount of mitigation required. eet of impact to each zone of the riparian buffer that requires mitigation. Calculate the

Zone 6c.
Reason for imps 6d.
Total Impact
(square feet)
Multiplier 6e.
Required mitigation
(square feet)
Zone 1 NIA N/A 3 (2 for Catawba) WA
Zone 2 NIA N/A 1.5 NIA
6f. Total buffer mitigation required: NONE
6g. If buffer mitigation is required,
permittee responsible riparian buffo iscuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
restoration, payment into an approved in-lieu fee fund). N/A
6h. Comments: N/A
Page 5 of 8
PCN Form - Version 1.3 December 10, 2008 Version
E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
la. Does the project include or is i
i
i adjacent to protected riparian buffers identified ® Yes ? No
w
th
n one of the NC Riparian uffer Protection Rules?
1b. If yes, then is a diffuse flow pla n included? If no, explain why.

Comments: this pipe extension
will not alter storm water runoff at this site
I ? Yes ® No
2. Storinwater Management Pla n
2a. What is the overall percent imp erviousness of this project? 20 %
2b. Does this project require a St water Management Plan? j ? Yes ED No
2c. If this project DOES NOT requi a Stormwater Management Plan, explain why: NCDOT state Permit No. NCS000250
2d. If this project DOES require a mrwater Management Plan, then provide a brief, narrative description of the plan: N/A
? Cerfified Local Govemment
2e. Who will be responsible for the review of the Stormwater Management Plan? ? DWQ Stormwater Program
? DWQ 401 Unit
3. Certified Local Government S tormwater Review
3a. In which local government's juri iction is this project? Vance County
? Phase II
3b. Which of the following locally-i mplemented stormwater management programs ? NSW
? USMP
apply (check all that apply): ? Water Supply Watershed
? Other:
3c. Has the approved Stormwater M anagement Plan with proof of approval been ? Yes ? No
attached? N/A
4. DWQ Stomrwater Program Rom riew
? Coastal counties

4a. Which of the following state-i
lamented stormwater management programs apply ? HQW
? ORW
(check all that apply): WA
? Session Law 2008-246
? Other.
4b. Has the approved Stormwater nagement Plan with proof of approval been
attached? N/A ? Yes ? No
b. DWQ 401 Unit Stormwater Rev iew
5a. Does the Stormwater Managem ent Plan meet the appropriate requirements? N/A ? Yes ? No
5b. Have all of the 401 Unit submitt I requirements been met? N/A
? Yes ? No
Page 6 of 8
PCN Form - Version 1.3 December 10, 2008 Version
F. Supplementary Information
1. Environmental Documentati on (DWQ Requirement)
1a. Does the project involve an ex penditure of public (federaYstate/local) funds or the
®Yes ? No
use of public (federaYstate) lar d?
1b. If you answered °yes'to the a ove, does the project require preparation of an
environmental document purl ant to the requirements of the National or State ? Yes ® No
(North Carolina) Environments Policy Act (NEPA/SEPA)?
tc. If you answered 'yes" to the a ve, has the document review been finalized by the
State Clearing House? (If so, ch a copy of the NEPA or SEPA final approval
letter.) ? Yes ? No
Comments: WA
2. Violations (DWQ Requireme t)
2a. Is the site in violation of DWQ % etland Rules (15A NCAC 21-1.0500), Isolated
Wetland Rules (15A NCAC 2H 1300), DWQ Surface Water or Wetland Standards, ? Yes ®No
or Riparian Buffer Rules (15A CAC 2B .0200)?
2b. Is this an after-the-fact permit plication? ? Yes ® No
2c. If you answered yes' to one o both of the above questions, provide an explanation o f the violation(s): WA
3. Cumulative Impacts (DWQ R ulrement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in
? Yes No
additional development, which Id impact nearby downstream water quality?
3b. If you answered "yes' to the a ve, 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.
N/A
4. Sewage Disposal (DWQ Requ irement)
4a. Clearly detail the ultimate treatm ent methods and disposition (non-discharge or discharge) of wastewater generated from
the proposed project, or avail Is capacity of the subject facility.
WA
of 8
:N Form - Version 1.3 December 10, 2008 Version
S. Endangered Species and De ;lgnated Critical Habitat (Corps Requirement)
5a. Will this project occur in or n an area with federally protected s
peCies or
habitat? E3
Yes ® No
5b. Have you checked with the US
i S concerning Endangered Species Ad
? Y
s
mpacts? e
® No
5c. If yes, indicate the USFWS Fe d Office you have contacted. ? Raleigh
? Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
htt:/ /nc-es/ s/co n r.html and NC Natural Heritage Program Database, Element Occurrences
8- Essential Fish Habitat (Corps Requirement)
ea. Will this project occur in or near an area designated as essential fish
habitat? ? Yes No
Bb. What data sources did you use to determine whether your site would impact Essentiah Fish Habitat?
h ://ocea .fl ri a a' .or / coraUms/viewer.htm

7. Historic or Prehistoric Cultu I Resources (Corps Requirement)
7s. Will this project occur in or naa an area that the state, federal or tribal
governments have designated
status (e.g., National Historic T s having historic or cultural preservation
st designation or properties significant in
? Yes ® No
North Carolina history and arch ieology)?
7b. What data sources did you use o determine whether your site would impact historic or archeological resources?
HPO's historic layer using GIS rcView database and http:ltqis.ncder.gov/hi)oweb/
8. Flood Zone Designation (Corps Requirement)
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8a. Will this project occur in a FE -designated 100-year floodpiain? ? Yes ® No
i
8b. If yes, explain how project meets FEMA requirements: N/A
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8c. What source(s) did you use to m ke the floodplain determination? htto //www ncflood s cem/

J. W. Bowman, P.E. ?1/ 10/14111
ApplicantlAgenfs Printed Name Applicard/Agenirs Signatu + Date
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