20140560 Ver 1_Application_20140710

Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.4 January 2009
• -nim MmagullwM0711
A. Applicant Information
1. Processing
1a. Type(s) of approval sought from the Carps: Section 404 Permit [] Section 10 Permit
I b. Specify Nationwide Permit (NWP) number.- 14 or General Permit (GP) number:
1 c. Has the NWP or GP number been verified by the Corps? G] Yes E] No
1 d. Type(s) of approval sought from the DWO (check all that apply):
401 Water Quality Certification — Regular 0 Non-404 Jurisdictional General Permit
0 401 Water Quality Certification — Express n Riparian Buffer Authorization
11 e. Is this notification solely for the record For the record only for DWQ For the record only for Corps Permit:
because written approval is not required? 401 Certification:
0 Yes No Yes El No
1 f. 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 Yes Eg No
or in-lieu fee program.
1g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h E] Yes E] No
below.
3. Owner Information
3a. Name(s) on Recorded Deed': North Carolina Department of Transportation
3b. Deed Book and Page No. N/A
3c. Res . ponsible Party (for LLC if N/A
Page 1 of 10
PCN Form — 'Version 1.4 January 2009

4. Applicant # : different from R.
4a. Appricant is: Agent Other, specify: Division 2 Environmental Officer
4c. Business name North Carolina Department of Transportation
4d. Street address:
P.O. Box 1557
4e.
City, state, zip;
Greenville, IBC 27835
4f.
"telephone no.:
252- 439 -2800
4g.
Fax no.:
252- 530 -3341
4h,
S.
5a.
Email address;
Agent/Consultant Information
Name: I
[e-mail]
(if applicable)
NIA,
5b. Business name
50. Street address:
5d. City, state, zip'.
5e. Telephone no.:
5f. Fax no..
5g. Email address:

B,. Project Information and Prior Project History
_........__..... ... .._..._. _
1. Property Identification
1 a. Property identification no. (tax IPIN or parcel ID):
Beaufort 255 Bridge to Pipe Replacement
1 b. Site coordinates (in decimal degrees): Latitude: 35.603113 Longitude: - 76.7439 75
1c. Property size: acres
2. Surface Waters
2a. Name of nearest body of mater to proposed project: Broad Creek Canal
lib. Water Quality Classification of nearest receiving water: C Sw; NSW
2c. River basins Tar-Pamlico
Project Description
3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application:
NGSR 1612 (lrerra oeia Road) is a paved secondary road. ,Agriculture dominates the landscape.
3b. List the total estimated acreage of all existing wetlands on the property: g
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property: 210
3d. Explain the purpose of the proposed project:
Bridge to (pipe replacement;; the existing bridge has deteriorated and needs replacement.
3e. Describe the overall! project in detail, including the type of equipment to be used:
The 120' long steel plank floor bridge will be replaced with a 3 -cell 9'x 13' reinforced concrete box culvert.
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Q yes Q No 0 Unknown
Corps or State been requested or obtained for this property !
Comments:
project ilncludin all prior phases) in the past?
4b. If the Corps made the jurisdictional determination, what type ® Preliminary [] Final
of determination was made?
4c. If yes" who delineated the jurisdictional areas? Agency /Consultant Company:
Name (if known): Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5. Project (History
5a. Have permits or certifications been requested or obtained for
®yes [D No ®U'nknown
this project (including all prior phases) in the past?
5b. If yes, explain in detail according to "help tile" instructions.
6. Future Project Plans
6a. is this a phased project? yes No
6b. If yes, explain.
Page 3 of
—Version PCN Form 0

C. Proposed III Impacts III IINII Ii ent
1. Impacts
1 a. Which sections were completed below for your project (check all that apply):
® Wetland's M Streams .... tributaries ® Suffers ®l Open waters El' Pond Construction
. Wetland Impacts
If there are wetiand impacts proposed on the site, then complete this question for each wetland area impacted.
2a.
2b.
2c.
2d,
2e.
2f.
Wetland impact
Type of impact
Type of wetland
Forested
Type of jurisdiction
' Area of
number
Corps (404,1!0) or
impact
Permanent (P) or
CMh,+11C (401, other)
(acres)
Tem ora T
W1 _
Choose one
Choose one
Yes/No
-
if4 -
Choose one
Choose one
Yes/No
-
3 -
Choose one
Choose one
YesiNo
W4 - Choose one Choose one YeslNo -
'il"U5 - Choose one Choose one Yes /No
W6 - Choose one Choose one Yes /No
2g. Total Wetland Impacts:
2h, Comments:
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.
3a.
3b,
3c.
3d.
3e.
3f.
3g.
Stream impact
Type of impact
Stream name
Perennial (PER) or
Type of
Average
Impact
number
intermittent (INT)"?
jurisdiction
stream
length
Permanent (P) or
width
(linear
Temporary (T)
(feet)
feet)
S1 P
Culvert
Broad Creek Canal
PER
Corps
20
2.10
S2 T
Diversion Channel
Broad Creek Carnal
PER
Corps
20
76
S3 -
Choose one
S4 -
Choose one
S5 -
Choose one
SS -
Choose one
3h. Total'streami and tributairy impacts
286
N. Comments:
Page 4 of
PCN • 2009

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
Area of impact (acres)
Permanent (P) or
type
Temporary (T)
01 -
Choose one
Choose
02 -
Choose one
Choose
03 - Choose one Choose
04 - Choose one Choose
4f. Total open water impacts
4g. Comments:
5. Pond! or Lake Construction
If and or lake construction proposed, then complete the chart below.
Sa.
5b.
5,c.
5&
5e.
Pond ID number
Proposed use or
Wetland Impacts (acres)
Stream Impacts (feet)
Upland
purpose of pond
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
Pi
Choose one
P2
Choose one
5f. Totall:
5g. Comments:
5h. Is a dam high hazard permit required?
Yes ❑ No If yes, permit ID no:
5i. 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.
6,a. Project is in which protected basin?
[] Neuse Tar-Pamlico ❑I Catawba [] Randleman n Other:
6b.
6c.
6d.
6e.
6f.
6g.
Buffer impact
Reason for impact
Stream name
Buffer
Zone 1
Zone 2
number—
mitigation
impact
impact
Permanent (P) or
required?
(square
(square
1tMRqra aJTJ
feet)
_feet
B1
Yes/No
B2
Yes/No
B3 -
YeslNo,
B4 -
Yes/No
B5 -
Yes/No
B6 -
Yes/No
6h. Total Buffer Impacts:
I
1-1KOTST17157- am
i�=

.. . ..... . ..... --------- - ................ ------
D. Impact Justification, and Mitigation
1. Avoidance and Minimization
la. Specifically describe measures taken to avoid or minimize the proposed impacts in dlesigning project.
No wetlands or buffers impacted. Permanent stream and temporary stream impacts are limited to what is needed to install the proposed pipe and
stabillize the inlet and outlet end from erosion.
1 b. Specifically describe imeasures taken to avoid or minimize the proposed impacts through construction techniques.
Use of existing roadway to operate construction equipment,
2. CompAnsato!y Mitigation for Impacts to 'Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for Yes n\ No
Impacts to Waters of the U.S. or Waters of the State?
2b. If yes, mitigation is required by (check all that apply):
n DWO El Corps
El Mitigation bank
2c. If yes, which mitigation option wiill be used for this
Payment to in-lieu fee program
project?
El Permittee Responsible Mitigation
3. Complete if Using I a Mitigation Bank
3a. Name of Mitigation Bank:
Type: Choose one Quantity:
3b. Credits Purchased (attach receipt and letter) Type, Choose one Quantity,
Type: Choose one Quantity:
. ....... .... . .. ... . ..
3c. Comments:
4. Complete if Making a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached.
E] Yes
4b. Stream mitigation requested:
linear feet
4c. If using stream mitigation, stream temperature-.
Choose one
4d. Buffer mitigation requested (DWQ only):
square feet
4e. Riparian wetland mitigation requested:
acres
4f. Non-riparian wetland mitigation requested'.
acres
4g. Coastal (tidal) wetland mitigation requested:
acres
,4h. Comments:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. IIf using a permittee responsible miitigation plan, provide a description of the proposed mitigation plan.
Page 6 i
PCN Form — Version, 1.4 January 21009

6. Buffer Mitigation (State, Regulated Riparian Buffer Rules) — required by DWO
6a. Will the project result in an impact within a protected riparian buffer that requires
Yes No
buffer mitigation?
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.
6c. 6d,
6e.
Zone Reason for impact Total impact Multiplier
Required mitigation
(square feet)
(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.gi., payment to private mitigation bank,
permittee, responsible riparian buffer restoration, payment into an approved in-lieu fee fund).
6h. Comments.-

E.
Stormwater Management and Diffuse Flow Plan (required by ©WQ)
1.
Diffuse Flow Plan
la.
Does the project include or is it adjacent to protected riparian buffers identified
E] Yes n 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
2.
Stormwater Mana ernent Plan
2a.
What is the overall percent imperviousness of this project?
%
2b.
floes this project require a Stormwater Management Plan?
El Yes ® No
2c.
If this ;project DOES NOT require a Stormwater Management Plan, explain why:
2d.
If this project DOES require a Stormwater Management Flan, then provide a grief, narrative description of the plan:
Roadway runoff will discharge through vegetated roadway shouldeWfill slopes prior to entering the stream. Vegetated treatment swales are not
required for this project.
2e.
Who will be responsible for the review of the Stormwater Management Plan?
DWR 401 Unfi
1
Certified Local Government Stormwater Review
3a.
In which local government's jurisdiction is this ro'ect?
NIA
E] Phase II'
❑ NSW
3b.
Which of the following locally-implemented stormwater management programs
® I.ISMP
apply (check all that apply):
❑ Water Supply Watershed '
® ether:
3c.
Has the approved Stormwater Management Plan with proof of approval been
n Yes E] No
attached?
4. i]WQ Stormwater Program Review
®Coastall counties
0HQW
4a.
Which of the following state - implemented stormwater management programs apply
EIORW
(check all that apply):
®Session Law 2006 -246
[90ther': NPDES Permit
4b.
Has the approved Stormwater Management Plan with proof of approval been
® Yes E] No
attached?
6. CDWQ 401 Unit Stormwater Review
5a.
Does the Stormwater Management 'Plan :meet the appropriate requirements?
] Yes E] No
5b.
Have all of the 401 Unit submittal requirements been met?
❑ Yes ®' No
Page rN r
PCN r —Version 2009

F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1 a. floes the project involve an expenditure of public (federal/state /local) funds or the
0 Yes El No
use of public (federal /state) land?
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
�°-��
E l Yes Q No
(North Carolina) Environmental Policy Act (NIEPA/SEPA)?
1c. If you answered "yes" to the above, has the document review been finalized by the
State Clearing blouse? (If so, attach a copy of the NEPA or SEPA final approval
n Yes n No
letter.)
Comments.:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NiCAC 2H .0500), Isolated
Wetland Rules (1'5A N'CAC 2I-1 .1'300)„ DWQ Surface Water or Wetland Standards,
El Yes [i No
or Riparian Duffer Rules (15A NCAC 2B MOO)?
2b. Is this an after- the -fact permit application?
El Yes E] 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. 'J Ul this protect (based on past and reasonably anticipated future impacts) result in
® Yes U 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.
. • "" of 10
PCN Form — Version 1.4 January 2009

6. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
Yes, n\I No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act
0 Yes EJ No
impacts?
5c. If yes, indicate the USFWS Field Office you have contacted.
5d. What data sources, did you use to determine whether your site would impact Endangered Species, or Designated Critical
Habitat?
Onsite field investigation by Jay Johnson ""No Effect"
S. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat?
es No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
NCVVRC - See attached email
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 E] Yes n\ No
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would, impact historic or archeological resources?
NCDOT HEU Historic Architecture and Archaeology
8. Flood Zone Designation (Corps Requirement)
8,a. Will this project occur in a FEMA-designated 100-y,ear floodplain? Yes No
8b. If yes, explain how project meets FEMA requirements-.
Designed to no-rise standards
8c. What source(s) did' you use to make the floodplain, determination?
FEMIA FIRM Maps
Jay B. Johnson
07-110-2014
Appliicanit/Agent"s Printed Name
Date
A E? Ag s Signature,
�n!
(Agent's i turo� only if an authorization
rficant
le fTom is provided.)