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Form Version 1 3 Dec 10 2008
Page 1 of 10
PCN Form — Version 1 3 December 10 2008 Version
Pre - Construction Notification PCN Form
A Applicant Information
1
Processing
1 a
Type(s) of approval sought from the
Corps
® Section 404 Permit ❑ Section 10 Permit
1 b Specify Nationwide Permit (NWP) number 3 or General Permit (GP) number
1 c
Has the NWP or GP number been verified by the Corps?
❑ Yes
® No
1 d
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
1 e
Is this notification solely for the record
because written approval is not required?
For the record only for DWQ 401
Certification
® Yes ❑ No
For the record only for Corps Permit
® Yes ❑ No
1f
Is payment into a mitigation bank or in lieu fee program proposed for mitigation
of impacts? If so attach the acceptance letter from mitigation bank or in lieu
fee program
❑ Yes
® No
1g
Is the project located in any of NC s twenty coastal counties If yes answer 1 h
below
❑ Yes
® No
1h
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes
® No
2
Project Information
2a
Name of project
Maintenance activity at pipe structure conveying UT to Harris Creek on SR 2929
(Peebles Road) in Wake County
2b
County
Wake
2c
Nearest municipality / town
Rolesville
2d
Subdivision name
2e
NCDOT only T I P or state
project no
3
Owner Information
3a
Name(s) on Recorded Deed
NCDOT
3b
Deed Book and Page No
3c
Responsible Party (for LLC if
applicable)
3d
Street address
3e
City state zip
3f
Telephone no
3g
Fax no
3h
Email address
Page 1 of 10
PCN Form — Version 1 3 December 10 2008 Version
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 individually list all open water impacts below
4a
4b
4c
4d
4e
Open water
Name of waterbody
impact number —
(if applicable)
Type of impact
Waterbody type
Area of impact (acres)
Permanent (P) or
Temporary T
01 ❑P ❑T
02 ❑P ❑T
03 ❑P ❑T
04 ❑P ❑T
417 Total open water impacts
00
4g Comments
5 Pond or Lake Construction
If pond 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 purpose
(acres)
number
of pond
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Flooded
P1
`P2
517 Total
5g Comments
5h Is a dam high hazard permit required
❑ Yes ❑ No If yes permit ID no
51 Expected pond surface area (acres)
5j Size of pond watershed (acres)
5k Method of construction
6 Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer then complete the chart below If yes then individually list all buffer impacts
below If any impacts require mitigation then you MUST fill out Section D of this form
6a
® Neuse El Tar Pamlico El Other
Project is in which protected basin?
❑ Catawba ❑ Randleman
6b
6c
6d
6e
6f
6g
Buffer impact
number —
Reason
Buffer
Zone 1 impact
Zone 2 impact
Permanent (P) or
for
Stream name
mitigation
(square feet)
(square feet)
Temporary T
impact
required?
61 ®P ❑ T
Stabilize
UT to Harris Creek
® Yes s
2 000 sf
F-1 Yes
B2 ❑P ❑T
❑ No
B3 ❑P ❑T
❑Yes
❑ No
6h Total buffer impacts
2 000 sf
61 Comments Buffer impact is only for constuction access Linear impact to buffer is 36 linear feet
Page 5 of 10
PCN Form — Version 1 3 December 10 2008 Version
6 Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a Will the project result in an impact within a protected riparian buffer that requires
buffer mitigation?
❑ Yes ® No
6b If yes then identify the square feet of impact to each zone of the riparian buffer that requires mitigation Calculate the
amount of mitigation required
Zone
6c
Reason for impact
6d
Total impact
(square feet)
Multiplier
6e
Required mitigation
(square feet)
Zone 1
3 (2 for Catawba)
Zone 2
1 5
6f Total buffer mitigation required
6g If buffer mitigation is required discuss what type of mitigation is proposed (e g payment to private mitigation bank
permittee responsible riparian buffer restoration payment into an approved in lieu fee fund)
6h Comments
Page 7 of 10
PCN Form — Version 1 3 December 10 2008 Version
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?
1 b
If yes then is a diffuse flow plan included? If no explain why
❑ Yes No
Comments Project serves to stabilize fill slope and re attach pipe segment
2
Stormwater Management Plan
2a
What is the overall percent imperviousness of this project?
0%
2b
Does this project require a Stormwater Management Plan?
❑ Yes ® No
2c
If this project DOES NOT require a Stormwater Management Plan explain why Impacts
are only to stabilize fill slope re
attach pipe segment and install rip rap streambank protection
2d
If this project DOES require a Stormwater Management Plan then provide a brief narrative
description of the plan
Construction of this project WILL NOT add any additional impervioius surface at the project
❑ 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?
N/A
❑ Phase II
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
❑ HQW
4a
Which of the following state implemented stormwater management programs apply
❑ ORW
(check all that apply)
❑ Session Law 2006 246
❑ Other
4b
Has the approved Stormwater Management Plan with proof of approval been
❑ Yes ❑ No
attached?
5
DWQ 401 Unit Stormwater Review
5a
Does the Stormwater Management Plan meet the appropriate requirements?
❑ Yes ❑ No
5b
Have all of the 401 Unit submittal requirements been met?
❑ Yes ❑ No
Page 8 of 10
PCN Form — Version 1 3 December 10 2008 Version
F
Supplementary Information
1
Environmental Documentation (DWQ Requirement)
la
Does the project involve an expenditure of public (federal /state /local) funds or the
® Yes
❑ No
use of public (federal /state) land?
lb
If you answered yes to the above does the project require preparation of an
environmental document pursuant to the requirements of the National or State
❑ Yes
® No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1c
If you answered yes to the above has the document review been finalized by the
State Clearing House? (If so attach a copy of the NEPA or SEPA final approval
❑ Yes
❑ No
letter )
Comments
2
Violations (DWQ Requirement)
2a
Is the site in violation of DWQ Wetland Rules (15A NCAC 2H 0500) 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
® No
additional development which could impact nearby downstream water quality?
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
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
Project will not generate sewage disposal
Page 9 of 10
PCN Form — Version 1 3 December 10 2008 Version
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