20211834 Ver 1_Sheek Street PCN_20211220

Page 1 of 21 PCN Form - Version 1.5, September 2020
Office Use Only
Corps Action ID no. [Click to enter.] Date received: [Click to enter.]
DWR project no. [Click enter.] Date received: [Click to enter.]
Site Coordinates:
Latitude (DD.DDDDDD): 35.899623
Longitude (DD.DDDDDD): 80.546471

Form Version 4, April 4, 2021

Pre-Construction Notification (PCN) Form
(Ver. 4, April 4, 2021))

For Nationwide Permits and Regional General Permits and corresponding Water Quality Certifications

Please note: fields marked with a red asterisk * are required. The form is not considered complete until all
mandatory questions are answered.

The online help file may be found at this link:
https://edocs.deq.nc.gov/WaterResources/0/edoc/624704/PCN%20Help%20File%202018-1-30.pdf
The help document may be found at this link:
http://www.saw.usace.army.mil/Missions/Regulatory-Permit-Program/Permits/2017-Nationwide-
Permits/Pre-construction-Notification/

Before submitting this form, please ensure you have submitted the Pre-Filing Meeting Request Form as
DWR will not be able to accept your application without this important first step. The Pre-Filing Meeting
Request Form is used to satisfy 40 C.F.R. Section 121.4(a) which states “At least 30 days prior to
submitting a certification request, the project proponent shall request a pre-filing meeting with the certifying
agency.” In accordance with 40 C.F.R. Section 121.5(b)(7), and (c)(5), all certification requests must
include documentation that a pre-filing meeting request was submitted to the certifying authority at least 30
days prior to submitting the certification request.   

Attach documentation of Pre-Filing Meeting Request to this Application.

Date of Pre-filing Meeting Request (MM/DD/YYYY) *: no longer applicable

DWR ID # Click to enter. Version Click to enter. (If applicable)

Page 2 of 21 PCN Form - Version 1.5, September 2020

A. Processing Information
County (counties) where project is located: * Davie Additional (if needed).
Is this a NCDMS project? *
(Click yes only if NCDMS is the applicant or co-
applicant)
☐ Yes ☒ No
Is this a public transportation project? *
(Publicly funded municipal, state, or federal road, rail,
or airport project)
☒ Yes ☐ No
Is this a NCDOT project? * ☒ Yes ☐ No
If yes, NCDOT TIP or state project number: Click to enter.
If yes, NCDOT WBS number: * 49785
1a. Type(s) of approval sought from the Corps: *
☒ Section 404 Permit (wetlands, streams, waters,
Clean Water Act)
☐ Section 10 Permit (navigable waters, tidal
waters, Rivers and Harbors Act)
Has this PCN previously been submitted? * ☐ Yes ☒ No
Please provide the date of the previous submission. * NA
1b. What type(s) of permit(s) do you wish to seek
authorization? *
☒ Nationwide Permit (NWP)
☐ Regional General Permit (RGP)
☐ Standard (IP)
This form may be used to initiate the standard/ individual permit process with the USACE. Please contact your Corps
representative concerning submittals for standard permits. All required items can be included as attachments and
submitted with this form.
1c. Has the NWP or GP number been verified by the Corps? * ☒ Yes ☐ No
NWP number(s) (list all numbers ): 14
RGP number(s) (list all numbers ): Click to enter.
Are you a federal applicant? ☐ Yes ☒ No
If yes, please provide a statement concerning compliance with the Coastal Zone Management Act *
NA
1d. Type(s) of approval sought from DWR (check all that apply): *
☒ 401 Water Quality Certification – Regular ☐ 401 Water Quality Certification– Express
☐ Non-404 Jurisdictional General Permit ☐ Riparian Buffer Authorization
☐ Individual 401 Water Quality Certification

Page 3 of 21 PCN Form - Version 1.5, September 2020
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.

To read more information on when this form is needed prior to application submission:
https://www.epa.gov/sites/production/files/2020-07/documents/clean_water_act_section_401_certification_rule.pdf
To view the form: https://edocs.deq.nc.gov/Forms/DWR-Pre-Filing-Meeting-Request

Is this a courtesy copy notification ☐ Yes ☒ No
1e. Is this notification solely for the record because written approval is not required? *
For the record only for DWR 401 Certification: * ☐ Yes ☒ No
For the record only for Corps Permit: * ☐ Yes ☒ No
1f. Is this an after-the-fact permit/certification application? * ☐ Yes ☒ No
1g. Is payment into a mitigation bank or in-lieu fee program proposed for
mitigation of impacts? ☒ Yes ☐ No
If yes, attach the acceptance letter from mitigation bank or in-lieu fee program.
1h. Is the project located in any of NC’s twenty coastal counties? * ☐ Yes ☒ No
1i. Is the project located within an NC DCM Area of Environmental
Concern (AEC)? * ☐ Yes ☒ No ☐ Unknown
1j. Is the project located in a designated trout watershed? * ☐ Yes ☒ No
If yes, you must attach a copy of the approval letter from the appropriate Wildlife Resource Commission Office.
Trout information may be found at this link: http://www.saw.usace.army.mil/Missions/Regulatory-Permit-
Program/Agency-Coordination/Trout.aspx

Page 4 of 21 PCN Form - Version 1.5, September 2020

B. Applicant Information
1a. Who is the primary contact? * Amy Euliss
1b. Primary Contact Email: * [e-mail]
1c. Primary Contact Phone: * (###)###-#### [phone]
1d. Who is applying for the permit/certification? * (check
all that apply) ☒ Owner ☐ Applicant (other than owner)
1e. Is there an agent/consultant for this project?* ☐ Yes ☒ No

2. Landowner Information
2a. Name(s) on Recorded Deed: * NCDOT Division 9
2b. Deed Book and Page No.: Click to enter.
2c. Contact Person (for corporations): Click to enter.
2d. Address *
Street Address: 375 Silas Creek Parkway
Address line 2: Click to enter.
City: Winston Salem
State/ Province/ Region: NC
Postal/ Zip Code: 27127
Country: USA
2e. Telephone Number: * (###)###-#### [phone]
2f. Fax Number: (###)###-#### Click to enter.
2g. Email Address: * [e-mail]

3. Applicant Information (if different from owner)
3a. Name: * Click to enter.
3b. Business Name (if applicable): Click to enter.
3c. Address: *
Street Address: Click to enter.
Address line 2: Click to enter.
City: Click to enter.
State/ Province/ Region: Click to enter.
Postal/ Zip Code: Click to enter.
Country Click to enter.
3d. Telephone Number: * (###)###-#### Click to enter.
3e Fax Number: (###)###-#### Click to enter.
3f. Email Address: * Click to enter.

Page 5 of 21 PCN Form - Version 1.5, September 2020

4. Agent/ Consultant (if applicable)
4a. Name: * Click to enter.
4b. Business Name: Click to enter.
4c. Address: *
Street Address: Click to enter.
Address line 2: Click to enter.
City: Click to enter.
State/ Province/ Region: Click to enter.
Postal/ Zip Code: Click to enter.
Country: Click to enter.
4d. Telephone Number: * (###)###-#### Click to enter.
4e Fax Number: (###)###-#### Click to enter.
4f. Email Address: * Click to enter.
Agent Authorization Letter:*
Attach a completed/signed agent authorization form or letter. A sample form may be found at this link:
https://www.saw.usace.army.mil/Missions/Regulatory-Permit-Program/Permits/2017-Nationwide-Permits/Pre-
construction-Notification/

Page 6 of 21 PCN Form - Version 1.5, September 2020
C. Project Information and Prior Project History
1. Project Information
1a. Name of project: * Sheek Treet Upgrade
1b. Subdivision name (if appropriate): Click to enter.
1c. Nearest municipality/town: * Mocksville

2. Project Identification
2a. Property identification number (tax PIN or parcel ID): Click to enter.
2b. Property size (in acres): Click to enter
2c. Project Address:
Street Address: Click to enter.
Address line 2: Click to enter.
City: Click to enter.
State/ Province/ Region: Click to enter.
Postal/ Zip Code: Click to enter.
Country: Click to enter.
2d. Site coordinates in decimal degrees (using 4-6 digits
after the decimal point): *
Latitude (DD.DDDDDD): * 35.899623
Longitude (-DD.DDDDDD): * -80.546471

3. Surface Waters
3a. Name of nearest body of water to proposed project: * UT to Leonard Creek
3b. Water Resources Classification of nearest receiving
water: *
Class C
The Surface Water Classification map may be found at this link:
https://ncdenr.maps.arcgis.com/apps/webappviewer/index.html?id=6e125ad7628f494694e259c80dd64265
3c. In what river basin(s) is your project located? * Yadkin-PeeDee
Choose additional (if needed)
3d. Please provide the 12-digit HUC in which the project is
located: *
030401011404
The Find Your HUC map may be found at this link:
https://ncdenr.maps.arcgis.com/apps/PublicInformation/index.html?appid=ad3a85a0c6d644a0b97cd069db238ac3

Page 7 of 21 PCN Form - Version 1.5, September 2020
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 existing site is an access road. The surrounding area includes a mix of industrial, commercial, and
residential uses.
4b. Have Corps permits or DWR certifications been obtained for this
project (including all prior phases) in the past? * ☐ Yes ☒ No ☐ Unknown
If yes, please give the DWR Certification number and/or Corps
Action ID (ex. SAW-0000-00000):
[Click to enter.]
[Click to enter.]
Attach any pertinent project history documentation
4b2. Is any portion of the work already complete? * ☐ Yes ☒ No
If yes, describe the completed work.
Click to enter text.
4c. List of other certifications or approvals/denials received from other federal, state or local agencies for work
described in this application not related to the 404 or 401.
Click to enter text.
4d. Attach an 8½ x 11” excerpt from the most recent version of the USGS topographic map indicating the location of
the project site.
4e. Attach an 8½ x 11” excerpt from the most recent version of the published County NRCS Soil Survey map
depicting the project site.
4f. List the total estimated acreage of all existing wetlands on the
property: 0 acres
4g. List the total estimated linear feet of all existing streams (intermittent
and perennial) on the property: 100 linear feet
4g1. List the total estimated acreage of all existing open waters on the
property: 0 acres
4h. Explain the purpose of the proposed project: *
We are requesting a Section 404 Nationwide Permit 14 from the US Army Corps of Engineers (USACE) for
stream impacts associated with upgrading existing Sheek Street from a 10’ gravel road to a paved road with 2,
11’ travel lanes and grassed shoulders. The project is part of an economic development project that will provide
improved access for Liberty Storage Facility.
4i. Describe the overall project in detail, including the type of equipment to be used: *
Standard road bulidng equipment will be used.
4j. Attach project drawings/site diagrams/depictions of impact areas for the proposed project.
4k. Will this activity involve dredging in wetlands or waters? * ☐ Yes ☒ No
If yes, describe the type of dredging, the composition of the dredged material, and the locations of disposal area.
Click to enter text.

Page 8 of 21 PCN Form - Version 1.5, September 2020

5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or in
proposed impact areas? * ☒ Yes ☐ No ☐ Unknown
Comments:
Click to enter text.
5b. If the Corps made a jurisdictional determination,
what type of determination was made? *
☐ Preliminary ☐ Approved ☐ Emailed concurrence
☒ Not Verified ☐ Unknown ☐ n/a
Corps AID number (ex. SAW-0000-00000): Click to enter.
5c. If 5a is yes, who delineated the jurisdictional
areas?
Name (if known): Amy Euliss, NCDOT (road)
Agency/Consultant Company: Phil May, Carolina
Ecosystems (development)
Other: Click to enter.
5d. List the dates of the Corps jurisdictional determination or State determination if a determination was made by
either agency.
Click to enter.
5d1. Attach jurisdictional determinations.

6. Future Project Plans
6a. Is this a phased project? ☐ Yes ☒ No
6b. If yes, explain.
Click to enter.
Are any other NWP(s), regional general permit(s), or individual permit(s) used, or intended to be used, to
authorize any part of the proposed project or related activity? This includes other separate and distant crossings
for linear projects that require Department of the Army authorization but don’t require pre-construction
notification.
No
7. Addresses of adjoining property owners, lessees, etc. whose property adjoins the waterbody (if more than can be
entered here, please attach a supplemental list)
This isn’t on the ePCN. If its needed, I can provide. The project is not an individual permit, so its not typically
requested.
8. Scheduling of activity:
The pipe replacement will take place as soon as permits are received.

Page 9 of 21 PCN Form - Version 1.5, September 2020

D. Proposed Impacts Inventory
1. Impacts Summary
1a. Where are the impacts associated with your project
(check all that apply):
☐ Wetlands ☐ Streams - tributaries
☐ Buffers ☐ Open Waters
☐ Pond Construction

2. Wetland Impacts
If there are wetland impacts proposed on the site, complete this table for each wetland area impacted.
2a.
Site #*
2a1.
Impact
Reason/Type*
2b.
Impact
Duration*
2c.
Wetland Type*
2d.
Wetland Name*
2e.
Forested
?*
2f.
Jurisdiction
Type*
2g.
Impact Area
(ac)*
W1 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W2 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W3 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W4 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W5 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W6 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W7 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W8 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W9 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W10 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W11 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W12 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W13 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W14 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
W15 Choose one Temp/ Perm Choose one Click to enter Y/N Choose one Click to enter
2g1. Total temporary wetland impacts Click to enter. ac
2g2. Total permanent wetland impacts Click to enter. ac
2g3. Total wetland impacts Click to enter. ac
2h. Type(s) of material being discharged and the amount of each type in cubic yards:
Click to enter text.
2i. Comments:
Click to enter text.

Page 10 of 21 PCN Form - Version 1.5, September 2020

3. Stream Impacts
If there are perennial or intermittent stream/ tributary impacts (including temporary impacts) proposed on the site,
complete this table for all stream/ tributary sites impacted.
** All Perennial or Intermittent streams must be verified by DWR or delegated local government

Site #*
3a
Impact
Reason*
3b.
Impact
Duration*
3c.
Impact Type*
3d.
Stream Name*
3e.
Stream
Type*
3f.
Jurisdiction
Type*
3g.
Stream Width
(avg ft) *
3h.
Impact length
(linear ft) *
S1 Site 1A: Rip
Rap stream
stablization
Permanent Fill (Incl.
Riprap)
UT to Leonard
Creek
Perennial Both 2 12
S2 Site 1A:
Dewatering
Temporary Dewatering UT to Leonard
Creek
Perennial Both 2 6
S3 Site 1B: 66”
CAAP
Permanent Crossing/
Culvert
UT to Leonard
Creek
Perennial Both 5 3
S4 Site 1B: Rip
Rap stream
stablization
Permanent Fill (Incl.
Riprap)
UT to Leonard
Creek
Perennial Both 5 14
S5 Site 1B: Bank
Stablization
Permanent Dewatering UT to Leonard
Creek
Perennial Both 5 6
S6 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S7 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S8 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S9 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S10 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S11 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S12 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S13 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S14 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S15 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S16 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S17 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S18 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S19 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
S20 Click to enter Temp/ Perm Choose one Click to enter Per/Int Choose one Click to enter Click to enter
3i1. Total jurisdictional ditch
impact: 0 linear ft
3i2. Total permanent stream
impacts: 35 linear ft
3i3. Total temporary stream
impacts: 6 linear ft
3i4. Total stream and ditch
impacts: 41 linear ft

Page 11 of 21 PCN Form - Version 1.5, September 2020
3j. Comments:
Existing stream is approximately 2' wide upstream of the existing culvert, and 5' wide downstream of the
existing culvert. The downstream stream width has been widened by the existing culvert. The new culvert has
been designed with a notched sill that will be 2' wide for the low flow notch and 1' wide for each high flow
notch. Floodplain benches will be constructed up and downstream of the pipe to match the width of the high
flow notches.

Page 12 of 21 PCN Form - Version 1.5, September 2020
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., individually list all open water impacts in the table below.
4a.
Site #*
4a1.
Impact Reason
4b.
Impact
Duration*
4c.
Waterbody Name*
4b.
Activity Type*
4e.
Waterbody
Type*
4f.
Impact area
(ac)*
O1 Click to enter. Temp/ Perm Click to enter. Choose one Choose one Click to enter.
O2 Click to enter. Temp/ Perm Click to enter. Choose one Choose one Click to enter.
O3 Click to enter. Temp/ Perm Click to enter. Choose one Choose one Click to enter.
O4 Click to enter. Temp/ Perm Click to enter. Choose one Choose one Click to enter.
O5 Click to enter. Temp/ Perm Click to enter. Choose one Choose one Click to enter.
4g. Total temporary open water impacts Click to enter. ac
4g. Total permanent open water impacts Click to enter. ac
4g. Total open water impacts Click to enter. ac
4h. Comments:
Click to enter.

5. Pond or Lake Construction
If pond or lake construction is proposed, complete the table below. (*This does NOT include offline stormwater
management ponds.)
5a.
Pond ID
#
5b.
Proposed use or
purpose of pond
5c.
Wetland Impacts (ac)
5d.
Stream Impacts (ft)
5e.
Upland
Impacts (ac) Flooded Filled Excavated Flooded Filled Excavated
P1 Choose one Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
P2 Choose one Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
P3 Choose one Click to
enter.
Click to
enter.
Click to
enter.
Click to
enter.
Click to
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Click to
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Click to
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5f. Total Click to
enter.
Click to
enter.
Click to
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Click to
enter.
Click to
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Click to
enter.
Click to
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5g. Comments:
Click to enter.
5h. Is a dam high hazard permit required? ☐ Yes ☐ No
If yes, permit ID no.: Click to enter.
5i. Expected pond surface area (acres): Click to enter.
5j. Size of pond watershed (acres): Click to enter.
5k. Method of construction:
Click to enter.

Page 13 of 21 PCN Form - Version 1.5, September 2020

6. Buffer Impacts (DWR requirement)
If project will impact a protected riparian buffer, then complete the chart below. Individually list all buffer impacts.
6a. Project is in which protected basin(s)?
* (Check all that apply.)
☐ Neuse ☐ Tar-Pamlico ☐ Catawba
☐ Jordan ☐ Goose Creek ☐ Randleman
☐ Other: Click to enter.

Site #*
6b.
Impact Type*
6c.
Impact Duration*
6d.
Stream Name*
6e.
Buffer
Mitigation
Required?*
6f.
Zone 1 Impact*
(sq ft)
6g.
Zone 2 Impact*
(sq ft)
B1 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B2 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B3 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B4 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B5 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B6 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B7 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B8 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B9 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B10 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B11 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B12 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B13 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B14 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B15 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B16 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B17 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B18 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B19 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
B20 Choose one Temp/ Perm Click to enter. Y/N Click to enter. Click to enter.
6h. Total temporary impacts: Zone 1: Click to enter. sq ft Zone 2: Click to enter. sq ft
6h. Total permanent impacts: Zone 1: Click to enter. sq ft Zone 2: Click to enter. sq ft
6h. Total combined buffer impacts: Zone 1: Click to enter. sq ft Zone 2: Click to enter. sq ft
6i. Comments:
Click to enter.
Please attach supporting documentation (impact maps, plan sheets, etc.) for the proposed project.

Page 14 of 21 PCN Form - Version 1.5, September 2020
E. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts through project design: *
There is an existing crossing. The new crossing length has been minimized as much as possible by utilizing a
taller headwall which minimizes slope lengths. Additionally, stream banks have been armored for long term
stability.
1b. Specifically describe measures taken to avoid or minimize proposed impacts through construction techniques: *
Erosion control measures have been designed to specifications outlined in NCDOTs BMP manual.

2. Compensatory Mitigation for Impacts to Waters of the U.S., Waters of the State, or Riparian Buffers
2a. If compensatory mitigation is required, by whom is it required? *
(check all that apply)
☐ DWR ☒ Corps
2b. If yes, which mitigation option(s) will be used for this
project? * (check all that apply)
☐ Mitigation Bank
☒ In Lieu Fee Program
☐ Permittee Responsible Mitigation

3. Complete if using a Mitigation Bank (Must satisfy NC General Statute143-214.11 (d1).)
3a. Name of mitigation bank: Click to enter.
3b. Credits purchased/requested: Type: Choose one Quantity Click to enter.
Type: Choose one Quantity Click to enter.
Type: Choose one Quantity Click to enter.
Attach receipt and/or approval letter.
3c. Comments:
Click to enter.

4. Complete if Using an In Lieu Fee Program
4a. Attach approval letter from in lieu fee program.
4b. Stream mitigation requested: 17 linear feet
4c. If using stream mitigation, what is the stream temperature: warm
NC Stream Temperature Classification Maps can be found under the Mitigation Concepts tab on the Wilmington
District’s RIBITS website: (Please use the filter and select Wilmington district)
https://ribits.usace.army.mil/ribits_apex/f?p=107:27:2734709611497::NO:RP:P27_BUTTON_KEY:0
4d. Buffer mitigation requested (DWR only): Click to enter. square feet
4e. Riparian wetland mitigation requested: Click to enter. acres
4f. Non-riparian wetland mitigation requested: Click to enter. acres
4g. Coastal (tidal) wetland mitigation requested: Click to enter. acres
4h. Comments:
Stream mitigation has been requested at a 2:1 ratio.

Page 15 of 21 PCN Form - Version 1.5, September 2020

5. Complete if Providing a Permittee Responsible Mitigation Plan
5a. If proposing a permittee responsible mitigation plan, provide a description of the proposed mitigation plan,
including mitigation credits generated.
Click to enter.
5b. Attach mitigation plan/documentation.

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) – DWR requirement
6a. Will the project result in an impact within a protected riparian buffer
that requires buffer mitigation? ☐ Yes ☒ No
If yes, please complete this entire section – please contact DWR for more information.
6b. If yes, identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required in the table below.
Zone
6c.
Reason for impact
6d.
Total impact
(square feet)

Multiplier
6e.
Required mitigation
(square feet)
Zone 1 Click to enter. Click to enter. Choose one Click to enter.
Zone 2 Click to enter. Click to enter. Choose one Click to enter.
6f. Total buffer mitigation required Click to enter.
6g. If buffer mitigation is required, is payment to a mitigation bank or
NC Division of Mitigation Services proposed? ☐ Yes ☐ No
6h. If yes, attach the acceptance letter from the mitigation bank or NC Division of Mitigation Services.
6i. Comments:
Click to enter.

Page 16 of 21 PCN Form - Version 1.5, September 2020
F. Stormwater Management and Diffuse Flow Plan (DWR requirement)
1. Diffuse Flow Plan
1a. Does the project include or is it adjacent to protected riparian buffers
identified within one of the NC Riparian Buffer Protection Rules? ☐ Yes ☒ No
1b. All buffer impacts and high ground impacts require diffuse flow or other form of stormwater treatment. If the
project is subject to a state implemented riparian buffer protection program, include a plan that fully documents
how diffuse/dispersed flow will be maintained.
All Stormwater Control Measures (SCM) must be designed in accordance with the NC Stormwater Design
Manual (https://deq.nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permit-
guidance/stormwater-bmp-manual).
Associated supplement forms and other documentation must be provided.
What Type of SCM are you
providing?
(Check all that apply)
☐ Level Spreader
☐ Vegetated Conveyance (lower seasonal high water table- SHWT)
☐ Wetland Swale (higher SHWT)
☐ Other SCM that removes minimum 30% nitrogen
☐ Proposed project will not create concentrated stormwater flow through the
buffer
For a list of options to meet the diffuse flow requirements, click here.
Attach diffuse flow documentation.

2. Stormwater Management Plan
2a. Is this an NCDOT project subject to compliance with NCDOT’s
Individual NPDES permit NCS000250? * ☒ Yes ☐ No
2b. Does this project meet the requirements for low density projects as
defined in 15A NCAC 02H .1003(2)? * ☐ Yes ☐ No
To look up low density requirements, click here:
http://reports.oah.state.nc.us/ncac/title%2015a%20-%20environmental%20quality/chapter%2002%20-
%20environmental%20management/subchapter%20h/15a%20ncac%2002h%20.1003.pdf
2c. Does this project have a stormwater management plan (SMP)
reviewed and approved under a state stormwater program or state-
approved local government stormwater program? *
☐ Yes ☐ No
☐ n/a – project disturbs < 1 acre
Note: Projects that have vested rights, exemptions, or grandfathering from state or locally implemented
stormwater programs or projects that satisfy state or locally-implemented stormwater programs through use of
community in-lieu programs should answer “no” to this question.
2d. Which of the following stormwater management program(s) apply?
(Check all that apply.)*
☐ Local Government
☐ State
If you have local government approval, please include the SMP on their overall impact map.
Local Government Stormwater Programs * ☐ Phase II ☐ USMP
☐ NSW ☐ Water Supply

Page 17 of 21 PCN Form - Version 1.5, September 2020
Please identify which local government stormwater program you are using. *
Click to enter.
State Stormwater Programs * ☐ Phase II ☐ HQW or ORW
☐ Coastal Counties ☐ Other
Comments:
A stormwater management plan is attached.

Page 18 of 21 PCN Form - Version 1.5, September 2020

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? * ☒ Yes ☐ No
1b. 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 ☒ 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 SEPA final approval letter.) * ☐ Yes ☐ No
Comments:
The project meets state minimum criteria rules. A MCDC has been prepared for documentation.

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),
Federally Non-Jurisdictional Wetlands /Classified Surface Waters
(15A NCAC 2H. 1400) DWR Surface Water or Wetland Standards or
Riparian Buffer Rules (15A NCAC 2B .0200)? *
☐ Yes ☒ No
2b. If you answered “yes” to the above question, provide an explanation of the violation(s):
Click to enter.

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 ☒ No
3b. If you answered “no”, provide a short narrative description:
The road is an existing road that is being upgraded. While there will be a new Liberty Storage facility created at
the end of the road, but we wouldn't anticipate the development from impacting downstream water quality.
3c. If yes, provide a qualitative or quantitative cumulative impact analysis in accordance with the most recent DWR
policy. (Attach .pdf)

4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project? * ☐ Yes ☐ No ☒ N/A
4b. If yes, describe in detail the treatment methods and dispositions (non-discharge or discharge) of wastewater
generated from the proposed project. If the wastewater will be treated at a treatment plant, list the capacity
available at that plant.
Click to enter.

Page 19 of 21 PCN Form - Version 1.5, September 2020

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? (IPAC weblink: https://www.fws.gov/ipac/ [fws.gov]) * ☒ Yes ☐ No
5b. Have you checked with the USFWS concerning Endangered Species
Act impacts? * ☐ Yes ☒ No
5c. If yes, indicate the USFWS Field Office you have contacted. Choose one
5d. Is another federal agency involved? * ☐ Yes ☒ No ☐ Unknown
If yes, which federal agency? Click to enter.
5e. Is this a DOT project located within Divisions 1-8? * ☐ Yes ☒ No
5f. Will you cut any trees in order to conduct the work in waters of the
U.S.? * ☒ Yes ☐ No
5g. Does this project involve bridge maintenance or removal? * ☐ Yes ☒ No
5g1. If yes, have you inspected the bridge for signs of bat use such as
staining, guano, bats, etc.? Representative photos of signs of bat use
can be found in the NLEB SLOPES, Appendix F, pages 3-7. ☐ Yes ☐ No
Representative photos of signs of bat use can be found in the NLEB SLOPES, Appendix F, pages 3-7. Link to
NLEB SLOPES document: http://saw-reg.usace.army.mil/NLEB/1-30-17-signed_NLEB-SLOPES&apps.pdf
If you answered yes to 5g1, did you discover any signs of bat use? * ☐ Yes ☐ No ☐ Unknown
If yes, please show the location of the bridge on the permit drawings/ project plans
5h. Does this project involve the construction/ installation of a wind
turbine(s)? * ☐ Yes ☒ No
If yes, please show the location of the wind turbine(s) on the permit drawings/ project plans (attach .pdf)
5i. Does this project involve blasting and /or other percussive activities
that will be conducted by machines, such as jackhammers,
mechanized pile drivers, etc.? * ☐ Yes ☒ No
If yes, please provide details to include type of percussive activity, purpose, duration, and specific location of this
activity on the property (attach .pdf)
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated
Critical Habitat? *
NC Natural Heritage database and site surveys. See cover letter for detailed endangered species information.
Attach consultation documentation.

6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as
an Essential Fish Habitat? * ☐ Yes ☒ No
Is there submerged aquatic vegetation (SAV) around
the project vicinity? * ☐ Yes ☒ No ☐ Unknown

Page 20 of 21 PCN Form - Version 1.5, September 2020
Will this project affect submerged aquatic vegetation? * ☐ Yes ☒ No ☐ Unknown
Explain: Click to enter.
6b. What data source(s) did you use to determine whether your site would impact Essential Fish Habitat? *
NOAA fish mapper

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)? *
☐ Yes ☒ No
7b. What data source(s) did you use to determine whether your site would impact historic or archeological
resources? *
NCDOT Cultural Resource review per the Section 106 Programmatic Agreement. Documentation is attached.
7c. Attach historic or prehistoric documentation.

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? * ☐ Yes ☒ No
8b. If yes, explain how the project meets FEMA requirements.
Please note that FEMA maps now refer to flood hazard zones and not 100 year floodplains. The project falls
within an area that has a 0.20% annual chance flood hazard, which equates to the 500 year floodplain.
8c. What source(s) did you use to make the floodplain determination?
FEMA maps

H. Miscellaneous
Comments:
Click to enter.
Attach pertinent documentation or attachments not previously requested

Page 21 of 21 PCN Form - Version 1.5, September 2020
I. Signature *
☐ By checking the box and signing below, I, as the project proponent, certify to the following:
• The project proponent hereby certifies that all information contained herein is true, accurate, and complete, to
the best of my knowledge and belief;
• 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;
• The project proponent hereby agrees 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”);
• The project proponent hereby agrees to conduct this transaction by electronic means pursuant to Chapter 66,
Article 40 of the NC General Statutes (the “Uniform Electronic Transactions Act”);
• The project proponent hereby understands that an electronic signature has the same legal effect and can be
enforced in the same way as a written signature; AND
• As the project proponent, I intend to electronically sign and submit the PCN/online form.
Full Name: * Click to enter.
Signature: * Click to enter.
Date: * Click to enter.