20211160 Ver 1_ePCN Application_20210727

DWR
Division of Water Resources
Pre-Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
June 1,2021 Ver4.1
Initial Review
Has this project met the requirements for acceptance in to the review process?*
6' Yes
✓ No
Is this project a public transportation project?*
R Yes r No
Change only if needed.
BIMS#Assigned* Version#*
20211160 1
Is a payment required for this project?*
(7 No payment required Reviewing Office*
✓ Fee received Winston-Salem Regional Office-(336)776-
✓ Fee needed-send electronic notification 9800
Select Project Reviewer*
Dave Wanucha:eads\djwanucha
Information for Initial Review
la.Name of project:
Asbury Road Pipe Replacement
1a.Who is the Primary Contact?*
Stephanie Braquet
1b.Primary Contact Email:* 1c.Primary Contact Phone:*
[e-mail] [phone]
Date Submitted
7/27/2021
Nearest Body of Water
Meadow Branch
Basin
Roanoke
Water Classification
C
Site Coordinates
Latitude: Longitude:
36.4830 -80.4323
A. Processing Information
County(or Counties)where the project is located:
Stokes
Is this a NCDMS Project
✓ Yes ( No
Is this project a public transportation project?*
( Yes r No
Is this a NCDOT Project?*
( Yes r No
(NCDOT only)T.I.P.or state project number:

WBS#(?)
DF17009.2085012
Pre-Filing Meeting Information
Is this a courtesy copy notification?*
6 Yes C- No
la.Type(s)of approval sought from the Corps:
7 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?*
C- Yes
6 No
lb.What type(s)of permit(s)do you wish to seek authorization?
7 Nationwide Permit(NWP)
r Regional General Permit(RGP)
r Standard(IP)
1c.Has the NWP or GP number been verified by the Corps?
C Yes G No
Nationwide Permit(NWP)Number: 03-Maintenance
NWP Numbers(for multiple NWPS):
1d.Type(s)of approval sought from the DWR:
I7 401 Water Quality Certification-Regular r 401 Water Quality Certification-Express
r Non-404 Jurisdictional General Permit r Riparian Buffer Authorization
r Individual 401 Water Quality Certification
le.Is this notification solely for the record because written approval is not required? *
For the record only for DWR 401 Certification: F Yes r No
For the record only for Corps Permit: C- Yes s No
If.Is this an after-the-fact permit application?*
C Yes ( No
1g.Is payment into a mitigation bank or in-lieu fee program proposed for mitigation of impacts?
C- Yes R No
1g.Is payment into a mitigation bank or in-lieu fee program proposed for mitigation of impacts?
C' Yes C No
lh.Is the project located in any of NC's twenty coastal counties?
CYes RNo
1j.Is the project located in a designated trout watershed?
C' Yes 6 No
B. Applicant Information
Id.Who is applying for the permit?
17 Owner r Applicant(other than owner)
le.Is there an Agent/Consultant for this project?*
✓ Yes t No
2.Owner Information
2a.Name(s)on recorded deed:
NCDOT
2b.Deed book and page no.:
2c.Contact Person:
2d.Address

Street Address
375 Silas Creek Pkwy
Address Line 2
aty State/Rovince/Region
Winston-Salem North Carolina
Postal/Zip Code Country
27127 United States
2e.Telephone Number: 2f.Fax Number:
[phone]
2g.Email Address:*
[e-mail]
C. Project Information and Prior Project History
1. Project Information
lb.Subdivision name:
(d apprcpriate)
1c.Nearest municipality/town:
Westfield
2. Project Identification
2a.Property Identification Number: 2b.Property size:
2c.Project Address
Street Address
Address Line 2
aty Slate/Rovince/Region
Postal/Zip Code Country
3.Surface Waters
3a.Name of the nearest body of water to proposed project:*
Meadow Branch
3b.Water Resources Classification of nearest receiving water:*
C
3c. What river basin(s)is your project located in?*
Roanoke
3d.Please provide the 12-digit HUC in which the project is located.
030101030106
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 area is rural with very few residential homes.
4b.Have Corps permits or DWR certifications been obtained for this project(including all prior phases)in the past?*
C Yes C No C Unknown
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:
65
4h.Explain the purpose of the proposed project:*
During Tropical Storm Zeta on November 11,2020 the pipe was overwhelmed and backed up,causing overtopping of the roadway and erosion of the shoulder.The outlet of the
existing pipe was undermined and fell off.
4i.Describe the overall project in detail,including indirect impacts and the type of equipment to be used:*
The stream will be dewatered using the pump around method.The existing 78"x 60'Corrugated Metal Pipe(CMP)will then be excavated and a new 13'x11"x 9'x5"Aluminum Structural
Plate Pipe Arch with 40'x6"x 14'0"prefabricated headwalls will be installed.
5.Jurisdictional Determinations
5a.Have the wetlands or streams been delineated on the property or proposed impact areas?*
6' Yes r No C Unknown

Comments:
5b.If the Corps made a jurisdictional determination,what type of determination was made?*
✓ Preliminary r Approved r Not Verified f Unknown F N/A
Corps AID Number:
5c.If 5a is yes,who delineated the jurisdictional areas?
Name(if known): Stephanie Braquet
Agency/Consultant Company: NCDOT Division 9
Other:
6. Future Project Plans
6a.Is this a phased project?*
✓ Yes f 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?
No
D. Proposed Impacts Inventory
1. Impacts Summary
1a.Where are the impacts associated with your project?(check all that apply):
r Wetlands 17 Streams-tributaries r Buffers
r Open Waters r Pond Construction
3.Stream Impacts
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 Placement of Fill Temporary Dewatering Meadow Branch Perennial Corps 10 20
Average(feet) (linear feet)
3i.Total jurisdictional ditch impact in square feet:
0
3i.Total permanent stream impacts: 3i.Total temporary stream impacts:
O 20
3i.Total stream and ditch impacts:
20
3j.Comments:
E. Impact Justification and Mitigation v
1.Avoidance and Minimization
1a.Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:
The proposed pipe will have prefabricated headwalls and the linear feet of the proposed pipe is less than the existing pipe.
1b.Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:
Erosion Control Plan has been designed in accordance with Design Standards in Sensitive Watersheds.
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?
C Yes ( No
2b.If this project DOES NOT require Compensatory Mitigation,explain why:
The proposed pipe is a shorter length than the exisiting pipe and the impacts are below the threshold that would require mitigation.The project has no permanent impacts,only
temporary for dewatering.
F. Stormwater Management and Diffuse Flow Plan (required by DWR)

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?
✓ Yes f No
If no,explain why:
The project is not located in the Neuse-Tar Pamlico River Basin.
2.Stormwater Management Plan
2a.Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?*
6 Yes r No
Comments:
The project is not adding impervious surface,and is not changing the existing stormwater drainage on the roadway.
G. Supplementary Information
1. Environmental Documentation
la.Does the project involve an expenditure of public(federal/state/local)funds or the use of public(federal/state)land?*
6 Yes rNo
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(NEPAISEPA)?*
✓ Yes (7 No
Comments:*
A FEMA compliance spreadsheet was used for this project because the damage was due to a natural disaster and it is being federally funded by
FEMA.The spreadsheet contains information regarding structures,location,cultural resources,permit requirements,endangered species,stream
classifications,wetlands,open waters,etc.
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 P No
3. Cumulative Impacts(DWR Requirement)
3a.Will this project result in additional development,which could impact nearby downstream water quality?*
✓ Yes f 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 r No 6' 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?*
✓ Yes ( No
5d.Is another Federal agency involved?*
6 Yes r No r Unknown
What Federal Agency is involved?
FEMA
5e.Is this a DOT project located within Division's 1-8?
✓ Yes (' No
5f.Will you cut any trees in order to conduct the work in waters of the U.S.?
✓ Yes f No
5g.Does this project involve bridge maintenance or removal?
✓ Yes (' No
5h.Does this project involve the construction/installation of a wind turbine(s)?*

CYesr 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.?
C Yes F No
5j.What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
NC Natural Heritage Data Explorer
6. Essential Fish Habitat(Corps Requirement)
6a.Will this project occur in or near an area designated as an Essential Fish Habitat?*
r Yes P. No
6b.What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
US Fish and Wildlife Database IPaC
7. Historic or Prehistoric Cultural Resources(Corps Requirement)
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?*
CYes ( No
7b.What data sources did you use to determine whether your site would impact historic or archeological resources?*
NC Natural Heritage Data Explorer
8. Flood Zone Designation(Corps Requirement)
8a.Will this project occur in a FEMA-designated 100-yearfloodplain?*
C Yes r No
8c.What source(s)did you use to make the floodplain determination?*
FEMA Flood Map
Miscellaneous
Please use the space below to attach all required documentation or any additional information you feel is helpful for application review.Documents should be combined into one
file when possible,with a Cover Letter,Table of Contents,and a Cover Sheet for each Section preferred.
Click the upload button or drag and drop files here to attach docurrent
location map.pdf 359.18KB
survey report.pdf 694.93KB
Signed_Cultural_Resources_form_Asbury Road.pdf 255.69KB
20210722 Asbury Road-Culvert Replacement plans.pdf 2.08MB
Asbury Rd topo map.pdf 828.19KB
Signed_NCDOT-DF170092085012_Pipe_Rp cover letter.pdf 272.76KB
rile rust be Nir or ldW
Comments
Signature
*
Fir 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:
Stephanie Braquet
Signature
Posrt
Date
7/27/2021