20210996 Ver 1_Pre-Construction Notification (PCN) Form_20210609

DWR
Division of Water Resources
Pre-Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
April 4,2O21 Ver 4
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%2OFile%202018-1-30.pdf
A. Processing Information
County(or Counties)where the project is located:*
Montgomery
Is this a NCDMS Project*
• Yes No
Click Yes,only t NCOtuB is the applicant a co-applicant.
Is this project a public transportation project?*
G Yes r No
This is any publicly funded by rrunicipal,state a federal funds road,rail,airport transportation project.
Is this a NCDOT Project?*
F Yes r No
(NCDOT only)T.I.P.or state project number:
SF-610190
WBS#*
17BP.8.R.135
(fa N21]0Tuse only)
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)
Has this PCN previously been submitted?*
✓ Yes
6 No
lb.What type(s)of permit(s)do you wish to seek authorization?*
17 Nationwide Permit(NWP)
I—Regional General Permit(RGP)
1—Standard(IP)
lc.Has the NWP or GP number been verified by the Corps?*
✓ Yes f No
Nationwide Permit(NWP)Number: 03-Maintenance
NWP Numbers(for multiple NWPS):
3&13
List all NW numbers you are applying for not cn the drop dawn list.
Id.Type(s)of approval sought from the DWR:*
check all that apply
17 401 Water Quality Certification-Regular r 401 Water Quality Certification-Express
r Non-404 Jurisdictional General Permit 1— Riparian Buffer Authorization
r Individual 401 Water Quality Certification
Pre-Filing Meeting Information
Before submitting this form please ensure you have submitted the Pre-Filing Meeting Request Form as we will not be able to accept your application without this important first step.The Pre-Filing
Meeting Request Form is used in accordance with 40 C.F.R.Section 121.4(a)"At least 30 days prior to submitting a certification request,the project proponent shall request a pre-filing meeting with the

certifying agency"and in accordance with 40 C.F.R.Section 121.5(b)(7),and(c)(5)all certification requests shall include documentation that a pre-filing meeting request was submitted to the certifying
authority at least 30 days prior to submitting the certification request.Click here to read more information on when this form is needed prior to application submission or here to view the form.
Is this a courtesy copy notification?*
6 Yes r No
le.Is this notification solely for the record because written approval is not required?
*
For the record only for DWR 401 Certification: i' Yes r No
For the record only for Corps Permit: r Yes 6 No
If.Is this an after-the-fact permit application?*
✓ Yes f No
1g.Is payment into a mitigation bank or in-lieu fee program proposed for mitigation of impacts?
f so,attach the acceptance letter fromndgation bank or in-lieu fee program
r Yes r No
Acceptance Letter Attachment
Cick the upload button or drag and drop files here to attach docurrent
SR 1110-Bridge 190-Division 8-YD 04.pdf 400.05KB
ALETYFE MIST BE FIT
Ih.Is the project located in any of NC's twenty coastal counties?*
✓ Yes f No
1j.Is the project located in a designated trout watershed?*
d Yes f No
Link to trout information:http://vwwo.saw.usace.army.mil/Missions/Regulatory-Permit-PrograrntAgency-Coordination/Trout.aspx
B. Applicant Information
1a.Who is the Primary Contact?*
Art King
1c.Primary Contact Phone:*
lb.Primary Contact Email:* (xxx)xxx-xxxx
[e-mail] [phone]
Id.Who is applying for the permit?*
FI Owner r Applicant(other than owner)
(Clack all that apply)
le.Is there an Agent/Consultant for this project?*
✓ Yes r No
2.Owner Information
2a.Name(s)on recorded deed:*
NCDOT Highway Division 8
2b.Deed book and page no.:
NA
2c.Contact Person:
(for Corporations)
2d.Address*
Street Address
121 DOT Dr.
Address Line 2
Dty State/Bovine/Region
Carthage NC
P ostal/Zip code Country
28327 Moore
2e.Telephone Number:*
(xxx)xxx-xxxx
[phone]
2f.Fax Number:
[phone]
(xx()smva m

2g.Email Address:*
[e-mail]
4.Agent/Consultant(if applicable)
4a.Name:*
Art King
4b.Business Name:
(if applicable)
NCDOT
4c.Address*
Street Address
121 DOT Drive
Address Line 2
Cty State/Bovine/I3gion
Carthage NC
Fbstal/Zlp Code Country
28327 Moore
4d.Telephone Number:* 4e.Fax Number:
[phone] [phone]
(xxx)xxx-)om (roa)xxx-xxxx
4f.Email Address:*
[e-mail]
Agent Authorization Letter*
Rease provide the Agent Authorization Letter if you are submtting this dccunent.
Agent Authorization.pdf 28.11 KB
RLE7YFEMJST BET
C. Project Information and Prior Project History UJ
1. Project Information
1a.Name of project:*
Montgomery Bridge 190
lb.Subdivision name:
(it appropriate)
na
lc.Nearest municipality/town:*
Mt Gilead
2. Project Identification l^J
2b.Property size:
2a.Property Identification Number: (in acres)
(tax RN cr parcel ID) 2
2c.Project Address
Street Address
Lillys Bridge Rd
Address Line 2
Criy State/Province/Region
NC
Fbstal/Zip Code Country
Montgomery County
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:*
35.210198 -80.042233
ex:34.208504 -77.708371
3.Surface Waters
3a.Name of the nearest body of water to proposed project:*

Clarks 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.*
030401040204
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:*
Replace a structurally deficient bridge(190)with a new structure.
The area is rural residential,agricultural.
4b.Have Corps permits or DWR certifications been obtained for this project(including all prior phases)in the past?*
✓ Yes r 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)
Click the upload button or drag and drop files here to attach document
Montgomery 190 topo.pdf 1.54MB
Re type mist 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)
aick the upload button or drag and drcp files here to attach document
Montgomery 190 soils map.pdf 2.14MB
Re type mist be pdf
4f.List the total estimated acreage of all existing wetlands on the property:
0.2 acres(estimated)
4g.List the total estimated linear feet of all existing streams on the property:
(intermittent and perennial)
200Ft
4h.Explain the purpose of the proposed project:*
To replace a structurally deficient bridge with a new modern structure with updated safety features.
4i.Describe the overall project in detail,including indirect impacts and the type of equipment to be used:*
The existing bridge will be demolished and removed and the new structure will be constructed in it's place in roughly the same location.The project will involve temporary and permanent
impacts to wetlands and waters of the US.
Anticipated equipment used will be;crane,track hoe,excavator,various trucks for hauling,compactors,paving equipment,grading equipment
4j.Please upload project drawings for the proposed project.
Click the upload button or drag and drcp files here to attach document
SF-6101 90_Permit Package_20210407.pdf 3.93MB
Re type mist be pdf
5.Jurisdictional Determinations
5a.Have the wetlands or streams been delineated on the property or proposed impact areas?*
rs Yes r No r Unknown
Comments:
5b.If the Corps made a jurisdictional determination,what type of determination was made?*
✓ Preliminary r Approved S Not Verified r Unknown r N/A
Corps AID Number:
Example:S4wt<2017-99999
5c.If 5a is yes,who delineated the jurisdictional areas?
Name(if known): W.Sullivan and M.Richards
Agency/Consultant Company: Kimley-Horne&Associates,Inc.
Other:
5d1.Jurisdictional determination upload

Click the upbad button or drag and drop files here to attach docunent
Br190_SA_NCDWR-Stream Form.pdf 136.89KB
Br190_WA-WB_UP_Eastern_Mountains_Piedmont_ADS_v1.05.pdf 85.2KB
Br190_WA-WB_WET_Eastern_Mountains_Piedmont_ADS_v1.05.pdf 85.31KB
Figure3_Bridge190_AerialMap.pdf 4.55MB
Pie type mist be FCF
6. Future Project Plans
6a.Is this a phased project?*
r Yes a 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.
No
D. Proposed Impacts Inventory l^U
1. Impacts Summary
1a.Where are the impacts associated with your project?(check all that apply):
17 Wetlands 17 Streams-tributaries r Buffers
I-Open Waters r Pond Construction
2.Wetland Impacts
If there are wetland impacts proposed on the site,then complete this question for each wetland area impacted.
"W."will be used in the table below to represent the word"wetland".
2a.Site#*(?) 2a1 Reason*(?) 2b.Impact type*(?) 2c.Type of W.* 2d.W.name* 2e.Forested* 2f.Type of 2g.Impact
Jurisdicition*(?) area*
2 fill P Bottomland Hardwood Forest na Yes Corps 0.010
(acres)
2 mechanized clearing P Bottomland Hardwood Forest na Yes Corps 0.080
(acres)
2g.Total Temporary Wetland Impact
0.000
2g.Total Permanent Wetland Impact
0.090
2g.Total Wetland Impact
0.090
2i.Comments:
Mechanized clearing is needed to accommodate movement of a utility(water line)
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*
S1 stabilization Permanent Bank Stabilization na Perennial Corps 25 86
Average(feet) (linear feet)
82 causeway Temporary Workpad/Causeway na Perennial Corps 25 30
Average(feet) (linear feet)
S3 structure Temporary Dewatering na Perennial Corps 25 126
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:
86
3i.Total temporary stream impacts:
156

3i.Total stream and ditch impacts:
242
3j.Comments:
Temporary impact for dewatering of 126ft may be needed to remove interior bent spread footers of the existing bridge.If the bents can be removed
cleanly without dewatering the impacts will not be used.
E. Impact Justification and Mitigation
1.Avoidance and Minimization
1a.Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:*
Project is designed to minimized the impacts to the adjacent wetlands while still providing a safe approach and structure.
The structure is designed to span the stream channel as much as possible and,minimize in water work or,placement of structures.
1b.Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
All construction equipment will be staged in the upland areas or,on the stream banks.NCDOT construction BMP's will be utilized during all phases of
construction.
2. Compensatory Mitigation for Impacts to Waters of the U.S.or Waters of the State
2a.Does the project require Compensatory Mitigation for impacts to Waters of the U.S.or Waters of the State?
(r Yes r No
2c.If yes,mitigation is required by(check all that apply):
17 DWR fJ Corps
2d.If yes,which mitigation option(s)will be used for this project?
n Mitigation bank fJ Payment to in-lieu fee r Permittee Responsible
program Mitigation
4. Complete if Making a Payment to In-lieu Fee Program
4a.Approval letter from in-lieu fee program is attached.
( Yes r No
4b.Stream mitigation requested:
(linear feet) 4c.If using stream mitigation,what is the stream temperature:
86 warm
NC Stream Temperature Classification Maps can be found under the Mitigation Concepts tab on the Wilmington District's RIBITS website.
4d.Buffer mitigation requested(DWR only): 4e.Riparian wetland mitigation requested:
(square feet) (acres)
na 0.09
4f.Non-riparian wetland mitigation requested: 4g.Coastal(tidal)wetland mitigation requested:
(acres) (acres)
na na
4h.Comments
6. Buffer mitigation(State Regulated Riparian Buffer Rules)-required by DWR
6a.Will the project result in an impact within a protected riparian buffer that requires buffer mitigation?If yes,you must fill out this entire form-please contact DWR for more
information.
CYes RNo
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?
C Yes ( No
For a list of options to meet the diffuse flow requirements,click here.
If no,explain why:
Yadkin-Pee Dee Basin
2.Stormwater Management Plan

2a.Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?*
( Yes C No
Comments:
The Stormwater Management plan is attached to the project plans.
LG. 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?*
✓ 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(NEPA/SEPA)?*
( Yes r No
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 SEPAfinal approval letter.)*
C Yes a No
Comments:*
State Minimum Criteria Checksheet
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)?*
C Yes ( 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?*
CYes 6' No
3b.If you answered"no,"provide a short narrative description.
Replacement of the existing deficient bridge with an new structure that will not change the function or,usage of the current roadway.
4.Sewage Disposal(DWR Requirement)
4a.Is sewage disposal required by DWR for this project?*
✓ Yes C No G 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 r No
5b.Have you checked with the USFWS concerning Endangered Species Act impacts?*
C Yes a No
5d.Is another Federal agency involved?*
C Yes r No ( Unknown
5e.Is this a DOT project located within Division's 1-8?*
( Yes C No
5j.What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
USF&W website information.
Onsite survey by NCDOT Environmental staff.
Consultation Documentation Upload
Click the upload button or drag and drop files here to attach docurrent
Montgomery 190 Endangered Species Survey Checklistl.pdf 411.53KB
File type mist be FCF
6. Essential Fish Habitat(Corps Requirement)
6a.Will this project occur in or near an area designated as an Essential Fish Habitat?*
C Yes G No
6b.What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
USF&W 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)?*
rYes 6' No
7b.What data sources did you use to determine whether your site would impact historic or archeological resources?*
NCDOT Cultural Resources
NC SHPO
7c.Historic or Prehistoric Information Upload
Click the upload button or drag and drop files here to attach document
Montgomery_190_HA_NSR.pdf 2.36MB
AR18-08-0009NoSurvey.pdf 1.15MB
Rle mist be FCF
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 f• No
8c.What source(s)did you use to make the floodplain determination?*
FEMA floodmaps
Miscellaneous U
Comments
Miscellaneous attachments not previously requested.
Click the upload button or drag and drop files here to attach document
Rle mist be FCF or l
Signature
*
17 By checking the box and signing below,I certify that:
• The project proponent hereby certifies that all information contained herein is true,accurate,and complete to the best of my knowledge and belief;and
• The project proponent hereby requests that the certifying authority review and take action on this CWA 401 certification request within the applicable reasonable period of time.
• 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:*
Art C.King
Signature*
C. OAT
Date
4/16/2021