20190145 Ver 2_Springside_PCN_2021Revision_20210310

tI r„ DWR
i I
Division of Water Resources
Pre-Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
September 29,2018 Ver 3
Please note:fields marked with a red asterisk below are required. You will not be able to submit the form until all mandatory questions are answered.
Also,if at any point you wish to print a copy of the E-PCN,all you need to do is right-click on the document and you can print a copy of the form.
Below is a link to the online help file.
https://edocs.deq.nc.gov/WaterResources/0/edoc/624704/PCN%20Help%20File%202018-1-30.pdf
A. Processing Information
County(or Counties)where the project is located:*
Forsyth
Is this project a public transportation project?*
B Yes r No
This is any publicly funded by rrunicipal,state or federal funds road,rail,airport transportation project.
Is this a NCDOT Project?*
✓ Yes s No
1a.Type(s)of approval sought from the Corps:*
17 Section 404 Permit(wetlands,streams and waters,Clean Water Act)
r Section 10 Permit(navigable waters,tidal waters,Rivers and Harbors Act)
lb.What type(s)of permit(s)do you wish to seek authorization?*
17 Nationwide Permit(NWP)
r Regional General Permit(RGP)
IT Standard(IP)
This form may be used to initiate the standard/individual permit process with the Corps. Please contact your Corps representative concerning submittals for standard permits. All required items that
are not provided in the E-PCN can be added to the miscellaneous upload area located at the bottom of this form.
1c.Has the NWP or GP number been verified by the Corps?*
✓ Yes 6 No
Nationwide Permit(NWP)Number: 14-Linear transportation
NWP Numbers(for multiple NWPS):
List all NN numbers you are applying for not on the drop down list.
1d.Type(s)of approval sought from the DWR:*
check all that apply
17 401 Water Quality Certification-Regular r 401 Water Quality Certification-Express
E Non-404 Jurisdictional General Permit r Riparian Buffer Authorization
r Individual Permit
1e.Is this notification solely for the record because written approval is not required?
*
For the record only for DWR 401 Certification: r Yes (7 No
For the record only for Corps Permit: r Yes F No
If.Is this an after-the-fact permit application?*
✓ Yes ( No
1g.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 B No
Acceptance Letter Attachment

Click the upload button or drag and drop files here to attach document
RLE1YFEMS'TBEFCF
I h.Is the project located in any of NC's twenty coastal counties?*
C Yes (R No
1j.Is the project located in a designated trout watershed?*
C Yes t: No
Link to trout information:http://www.saw.usace.army.mil/Missions/Regulatory-Permit-ProgramfAgency-Coordination/Trout.aspx
B. Applicant Information
1a.Who is the Primary Contact?*
Cynthia C.Lancaster
1c.Primary Contact Phone:*
lb.Primary Contact Email:* (roocpooc->000c
[e-mail] [phone]
1d.Who is applying for the permit?*
17 Owner I?Applicant(other than owner)
(Check all that apply)
le.Is there an Agent/Consultant for this project?*
G' Yes C No
2. Owner Information
2a.Name(s)on recorded deed:*
JAMES E RHODES AND LESLIE G FRY
2b.Deed book and page no.:
LOT NO 102,BLOCK NO 4264
2c.Responsible party:
(for Cnporations)
2d.Address*
Street Address
0 EDGEWATER DRIVE
Address Line 2
Clty State/Rovince/R3gien
CLEMMONS NC
Retal/Zp Cade Country
27012 US
2e.Telephone Number:*
(wc) c-
[phone]
2f.Fax Number:
(eroc)xoc-xxm
2g.Email Address:*
[e-mail]
2a.Name(s)on recorded deed:*
MARVN G CREWS
2b.Deed book and page no.:
LOT NO 004,BLOCK NO 4264
2c.Responsible party:
(for Corporations)
2d.Address*
Street Address
0 SPRINGSIDE DRIVE
Address Line 2
Cy State/Rovince/I3gion
CLEMMONS NC
Postal/Zp Cade Country
27012 US
2e.Telephone Number:*
( ) -
[phone]

2f.Fax Number:
(xxx)xxx-xxxX
2g.Email Address:*
[e-mail]
2a.Name(s)on recorded deed:*
RENEE DAVIS BROOKS
2b.Deed book and page no.:
LOT NO 005,BLOCK 4264
2c.Responsible party:
(for Corporations)
2d.Address*
Street Address
3211 SPRINGSIDE DR
Address Line 2
City State/Ft-evince/Ragien
CLEMMONS NC
Postal/Zip Cade Country
27012 US
2e.Telephone Number:*
(x)cx)xxx-xxxx
[phone]
2f.Fax Number:
(xxx)xxx-xxw
2g.Email Address:*
[e-mail]
2a.Name(s)on recorded deed:*
VILLAGE OF CLEMMONS(SPRINGSIDE DRIVE ROW)
2b.Deed book and page no.:
NOT APPLICABLE
2c.Responsible party:
(for Corporations)
2d.Address*
Street Address
3800 DILLON INDUSTRIAL DRIVE
Address Line 2
at/ State/Bovine/Ragion
CLEMMONS NC
Postal/ZZp Code Country
27012 US
2e.Telephone Number:*
(x)0)xxx-xxxx
[phone]
2f.Fax Number:
(xicrpoa-xxxx
2g.Email Address:*
[e-mail]
3.Applicant Information(if different from owner)
3a.Name:*
Village of Clemmons(owns ROW/is acquiring property and
easements)
34(. g(, ss Name:
3c.Address*

Street Address
3800 DILLON INDUSTRIAL DRIVE
Address Line 2
Qty State/R-ovince/Region
CLEMMONS NC
Postal/Zp Cade Country
27012 US
3d.Telephone Number:* 3e.Fax Number:
[phone] [phone]
(xxx)xxx-xxxx (>o«)xxx-xxxx
3f.Email Address:*
[e-mail]
4.Agent/Consultant(if applicable)
4a.Name:*
Cynthia C.Lancaster,P.E.
4b.Business Name:
(if applicable)
LJB Inc.
4c.Address*
Street Address
311-A S.Main St
Address Line 2
DIp State/Rovince/Region
Kernersville NC
Postal/Zip Code Country
27284 US
4d.Telephone Number:* 4e.Fax Number:
[phone] [phone]
(xxx)xxx-xxxx (>oo()xxx-xxxx
4f.Email Address:*
[e-mail]
Agent Authorization Letter*
Reese provide the Agent Authorization Letter lf you are subnitting this docunent.
4679_001.pdf 49.32KB
FLE-IYFEMST BE FIT
C. Project Information and Prior Project History L)
1. Project Information
1a.Name of project:*
Springside Culvert Replacement
lb.Subdivision name:
(if appropriate)
1c.Nearest municipality/town:*
Village of Clemmons
2. Project Identification
2a.Property Identification Number: 2b.Property size:
(tax RN or parcel ID) (in acres)
2c.Project Address
Street Address
Springside Drive
Address Line 2
Oty State/Province/Region
Clemmons NC
Postal/Zp Code Country
27012
2d. Site coordinates in decimal degrees
Please collect site coordinates in decimal degrees.Use between 4-6 digits(unless you are using a survey-grade GPS device)after the decimal place as appropriate,based on how the location was
determined. (For example,most mobile phones with GPS provide locational precision in decimal degrees to map coordinates to 5 or 6 digits after the decimal place.)

Latitude:* Longitude:*
36.03713 -80.37367
ex:34.208504 -77.796371
3.Surface Waters
3a.Name of the nearest body of water to proposed project:*
Muddy Creek
3b.Water Resources Classification of nearest receiving water:*
C
Surface Water Lookup
3c. What river basin(s)is your project located in?*
Yadkin-PeeDee
3d.Please provide the 12-digit HUC in which the project is located.*
030401011306
River Basin Lookup
4. Project Description and History
4a.Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this application:*
The location of the proposed culvert replacement is on Springside Drive,which is a dead-end Village of Clemmons street within a residential area.On the upstream side is a privately-
owned pond.The original outlet for the pond failed long ago and the pond has for many years been drained by 4-18"CMP's with inverts roughly only 2.5 ft below the top of the road.
Approximately 183 acres of watershed is drained to Springside pond,including 90 acres north of 1-40.Due to the hydraulic inadequacy of the existing outlets,the road may be
overtopped multiple times within a year.The downstream side of the roadway embankment is very steeply sloped and has been subjected to substantial erosion over time,requiring the
Village to heavily reinforce the slopes in order to protect the roadway.The outlet discharges to private property,but the stream then flows through a neighborhood park to the next
crossing at Greendale Way.Geotechnical investigation indicated that the existing roadway embankment construction for Springside Drive was not done in a manner adequate to
function as a dam and would require significant improvements if the Village wanted to maintain the pond.
4b.Have Corps permits or DWR certifications been obtained for this project(including all prior phases)in the past?*
r Yes 6 No r Unknown
4d.Attach an 8 1/2 X 11 excerpt from the most recent version of the USGS topographic map indicating the location of the project site.(for DWR)
pick the upload button or drag and drop files here to attach documrent
Springside_PCN_USGS_Map.pdf 666.49KB
Retype must be pdf
4e.Attach an 8 1/2 X 11 excerpt from the most recent version of the published County NRCS Soil Survey map depicting the project site.(for DWR)
Click the upload button or drag and drop files here to attach document
Springside_PCN_SoilMap.pdf 97.76KB
Rle type mist be pdf
4f.List the total estimated acreage of all existing wetlands on the property:
0
4g.List the total estimated linear feet of all existing streams on the property:
(intermittent and perennial)
74
4h.Explain the purpose of the proposed project:*
The purpose of the proposed project is to improve flood conveyance under Springdale Drive so that the road is protected from overtopping and to rebuild the eroded embankment on a
stable and safe slope.The project is a public safety measure because the current conditions threaten the integrity of the roadway embankment.
4i.Describe the overall project in detail,including indirect impacts and the type of equipment to be used:*
The pond will be permanently drained as part of the culvert replacement.The contractor is expect to keep a pump in operation,routing the discharge hose through
one of the existing CMP's. The existing pipes will remain in place to provide flood conveyance as needed until the new pipes are in place and operational. The
contractor will install a coffer dam to facilitate pumping out and excavating an area in the southeast corner of the existing lake. Two 48"pipes will be bored and
jacked through the embankment from the downstream side. A new stream channel will be constructed to partially replace the filling of the existing natural channel
area immediately downstream of the present outlet. Because the existing pond has a large amount of sediment,it will be necessary to excavate a stream channel
along the south pond bank to the outlet structure for the new pipes. A check dam will be constructed prior to removal of the coffer dam and remain in place until the
pond bottom is vegetated and stabilized. The existing drainage pipe culverts will be removed as part of the project and the areas backfilled per recommendations
from the geotechnical engineer.See project narrative for additional information.
It is expected that the contractor will use an excavator,bulldozer,backhoe,crane,and dump trucks to accomplish the excavation work and installation of the culvert.
4j.Please upload project drawings for the proposed project.
tlickthe upload button or drag and drop files here to attach document
SpringsideCulvert_Jan30_PCN.pd 5.56MB
f Retype mist be pdf
5.Jurisdictional Determinations
5a.Have the wetlands or streams been delineated on the property or proposed impact areas?*

Yes r No r Unknown
Comments:
See attached report from Piedmont Environmental
5b.If the Corps made a jurisdictional determination,what type of determination was made?*
r Preliminary r Approved r Not Verified r Unknown C' N/A
Corps AID Number:
Example:SAW-2017-99999
5c.If 5a is yes,who delineated the jurisdictional areas?
Name(if known): Brad Luckey
Agency/Consultant Company: Piedmont Environmental,Inc.
Other:
5d1.Jurisdictional determination upload
dick the upload button or drag and drop files here to attach document
Pilot Project 3880-Springside Dr-Wet Report_8.22.18.pdf 3.48MB
Rle type rrust be FOF
6. Future Project Plans
6a.Is this a phased project?*
r Yes /7 No
Are any other NWP(s),regional general permit(s),or individual permits(s)used,or intended to be used,to authorize any part of the proposed project or related activity?This
includes other separate and distant crossing for linear projects that require Department of the Army authorization but don't require pre-construction notification.
D. Proposed Impacts Inventory U
1. Impacts Summary
1a.Where are the impacts associated with your project?(check all that apply):
r Wetlands fJ Streams-tributaries r Buffers
17 Open Waters r Pond Construction
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.
"S"will be used in the table below to represent the word"stream".
3a.Reason for impact*(?) 3b.lmpact type* 3c.Type of impact* 3d.S.name* 3e.Stream Type* 3f.Type of 3g.S.width* 3h.Impact
(?) Jurisdiction* length*
Si Stream relocation-net loss Permanent Net loss(fill) unnamed trib Perennial Both 15 33
Average(feet) (linear feet)
Average(feet) (linear feet)
**All Perennial or Intermittent streams must be verified by DWR or delegated local government.
3i.Total jurisdictional ditch impact in square feet:
0
3i.Total permanent stream impacts:
33
3i.Total temporary stream impacts:
0
3i.Total stream and ditch impacts:
33
3j.Comments:
Assumes jurisdictional stream is from end of 18"CMPs to project limits,even though the upper 20 feet where the culvert extension will impact is really
more part of the embankment than part of a stream.Riprap will not extend for the entire 54 feet,but the intent is to re-use some of the onsite
stone/rubble in the initial pool area.Bed stabilization/energy dissipation will transition to boulders and smaller stone.
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. Site#*(?) 4a1.Impact Reason 4b.Impact type*(?) 4c.Name of wate rbody(?) 4d.Activity type* 4e.Waterbody type* 4f.Impact
area*
P1 Culvert extension P unnamed pond Culverts excavatior pond 0.02
(acres)
P2 Dewatering T unnamed pond Excavation Pond 0.02
(acres)
P3 Fill T unnamed pond Fill Pond 0.05
(acres)
4g.Total temporary open water Impacts:
0.07
4g.Total permanent open water impacts:
0.02
4g.Total open water impacts:
0.09
4h.Comments:
Pond impact areas are shown on Figure 1 of attached narrative.
E. Impact Justification and Mitigation
1.Avoidance and Minimization
la.Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:*
The project will improve the aquatic function through the area relative to what now exists in the pond that is so heavily filled with
sediment,with the outlet culverts discharging over ten feet above the natural stream bed. The stream immediately downstream of
the existing culverts has been impacted by the riprap placed on the banks to provide protection against erosion,some of which over
time has been transported down to the stream bed.The stream channel downstream of the existing culverts is thus degraded.
Although the revised project involves a net loss of downstream channel length,the flow through the pond and outlet will be much
more gradual than the existing drastic drop and the outlet pipes will discharge on a mild slope at an elevation appropriate for the
natural stream channel. The excavation of a stream channel through the pond bottom area will enhance the aquatic function
through the area relative to what exists in the pond that is so heavily filled with sediment.
lb.Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
The project is phased to facilitate use of the existing pipes to manage storm flows until the new pipes and channel are in place. A
coffer dam will facilitate excavation of an area to which pipes can be bored and jacked from the downstream side.
2.Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
Yes NO
26,pgpSstb gjeptlgSIpjO.q ipPPOjnteN{itgteiiyrylfgggtIKKO INWPWl,:of the U.S.or Waters of the State?
NC Stream Temperature Classification Maps can be found under the Mitigation Concepts tab on the Wilmington District's RIBITS website.
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
***Recent changes to the stormwater rules have required updates to this section.***
1. Diffuse Flow Plan
la.Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian Buffer Protection Rules?
r Yes 6 No
For a list of options to meet the diffuse flow requirements,click here.
If no,explain why:
Not within a watershed where NC Riparian Buffer Protection Rules are applicable.
2. Stormwater Management Plan
2a.Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?*
C Yes e No
2b.Does this project meet the requirements for low density projects as defined in 15A NCAC 02H.1003(2)?*
C Yes C No
To look up low density requirement click here 15A NCAC 02H.1003(2).
Comments:
No new impervious area associated with the project.
G. Supplementary Information

1. Environmental Documentation
1a.Does the project involve an expenditure of public(federal/state/local)funds or the use of public(federal/state)land?*
r Yes r No
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(North Carolina)
Environmental Policy Act(NEPNSEPA)?*
✓ Yes 6' No
Comments:*
Village of Clemmons will spend local public funds for the culvert replacement.No state or federal funds or lands will be used.
2.Violations(DWR Requirement)
2a.Is the site in violation of DWR Water Quality Certification Rules(15A NCAC 2H.0500),Isolated Wetland Rules(15A NCAC 2H.1300),or DWR Surface Water or Wetland Standards or
Riparian Buffer Rules(15A NCAC 2B.0200)?*
✓ Yes r No
3. Cumulative Impacts(DWR Requirement)
3a.Will this project(based on past and reasonably anticipated future impacts)result in additional development,which could impact nearby downstream water quality?*
✓ Yes r: No
3b.If you answered"no,"provide a short narrative description.
4. Sewage Disposal(DWR Requirement)
4a.Is sewage disposal required by DWR for this project?*
✓ Yes (' No N/A
5. Endangered Species and Designated Critical Habitat(Corps Requirement)
5a.Will this project occur in or near an area with federally protected species or habitat?*
✓ Yes 6' No
5b.Have you checked with the USFWS concerning Endangered Species Act impacts?*
✓ Yes 6 No
5d.Is another Federal agency involved?*
✓ Yes G No r Unknown
5e.Is this a DOT project located within Division's 1-8?*
✓ Yes r No
5f.Will you cut any trees in order to conduct the work in waters of the U.S.?*
✓ Yes r No
5g.Does this project involve bridge maintenance or removal?*
✓ Yes c No
Link to the NLEB SLOPES document: http://saw-reg.usace.amry.mil/NLEB/1-30-17-signed_NLEB-SLOPES&apps.pdf
5h.Does this project involve the construction/installation of a wind turbine(s)?**
✓ Yes 6 No
5i.Does this project involve(1)blasting,and/or(2)other percussive activities that will be conducted by machines,such as jackhammers,mechanized pile drivers,etc.?*
r Yes 6 No
5j.What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
Reviewed habitat information for threatened/endangered species list received from iPAC website on 1/29/2019 and completed their onsite review
process.No critical habitat is within the project area.
Consultation Documentation Upload
dick the upload button or drag and drop files here to attach docurrent
Fie type Host be PDF
6. Essential Fish Habitat(Corps Requirement)
6a.Will this project occur in or near an area designated as an Essential Fish Habitat?*
✓ Yes c No
6b.What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
Essential Fish Mapper website

7. Historic or Prehistoric Cultural Resources(Corps Requirement)
Link to the State Historic Preservation Office Historic Properties Map(does not include archaeological data: http://gis.ncdcr.gov/hpoweb/
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 status(e.g.,National Historic
Trust designation or properties significant in North Carolina history and archaeology)?*
C Yes 6 No
7b.What data sources did you use to determine whether your site would impact historic or archeological resources?*
accessed and checked website link to SHPO map on 1/22/2019
7c.Historic or Prehistoric Information Upload
aick the upload button or drag and drop files here to attach document
Hie crust be FIT
8. Flood Zone Designation(Corps Requirement)
Link to the FEMA Floodplain Maps: https://msc.fema.gov/portal/search
8a.Will this project occur in a FEMA-designated 100-year floodplain?*
r Yes G No
8c.What source(s)did you use to make the floodplain determination?*
Accessed and checked FEMA website listed above on 1/22/2019.Project area is not within a FEMA-designated 100-year floodplain.
Miscellaneous
Comments
see attached project narrative
Miscellaneous attachments not previously requested.
aick the upload button or drag and drop files here to attach document
Springside Pond_PCN_Narrative.pdf 1.66MB
Fle must be f-0F or ME
Signature
*
I7 By checking the box and signing below,I certify that:
• I have given true,accurate,and complete information on this form;
• I agree that submission of this PCN form is a"transaction"subject to Chapter 66,Article 40 of the NC General Statutes(the"Uniform Electronic Transactions Act");
• I agree to conduct this transaction by electronic means pursuant to Chapter 66,Article 40 of the NC General Statutes(the"Uniform Electronic Transactions Act");
• I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature;AND
• I intend to electronically sign and submit the PCN form.
Full Name:*
Cynthia C.Lancaster
Signature
Cirkilk C. Lahe r..f.
Date
1/30/2019