20141110 Ver 1_Application_20141021

PAT MCCRORY
GOVERNOR
� "�`"�
�,��
STATE OF NORTH CAROLINA
DEPARI'NIENT' OF TRANSPORTATION
October 21, 2014
SUBJECT: Stokes County — SR 1945 Rosebud Road
Mr. John Thomas
US Army Corps of Engineers
3331 Heritage Trade Dr.
Suite 105
Wake Forest, NC 27615
Dear Mr. Thomas,
ANTHONYJ.TATA
SPCRE'IARY
In an efFort to obtain the necessary permits for the subject pipe replacement we aze providing a
pre-construction notification application with supporting documentation. This is a permit for a defined
stream with distinct stream banks. The existing pipe is an 18-inch CMP, 40-feet long it is undeo-sized and
eroding back into the roadbed. NCDOT would like to replace this pipe with a 48-inch CMP, 40-feet long
with a headwall.
No endangered species were found on 10/02/2014. During construction, which is expected to take
two weeks, erosion control devices will be installed. All disturbed areas will be re-vegetated and the project
will be released by NCDOT's Roadside Field Operations Engineer/Technician once 80% vegetative cover
is achieved. We believe this project can be accomplished under Nationwide Permit 3 for the 4-feet of
temporary unpact to the stream due to an impervious dike used for dewatering. Dewatering is allowed
under a Nationwide 3 permit; however, Stokes County is designated as a trout counry by the North Cazolina
Wildlife Resources Commission. This is a courtesy copy for NCDENR-DWR, the WBS number for this
project is 9208511.
If you have any questions, comments or need additional information after reviewing this materia]
please contact me at [phone]. Thank you for your cooperation in this matter.
Enclosures
CC: Mr. Dave Wanucha, NCDENR-DWR, Envuonmental Senior Specialist- email
Ms. Marla Chambers, NCWRC- Westem NCDOT Coordinator- email
Mr. Iason Mays, U.S. Fish and Wildlife Service- Fish and Wildlife Biologist- email
Mr. Pat Ivey, P.E., Division Engineer
Mr. John Rhyne, P.E., Division Maintenance Engineer
Mr. Daniel Horne, Stokes County Maintenance Engineer
Mrs. Kiera Keen, Division 9 Roadside Environmental Technician
Division of Highways • Divisio� Nine • 375 Silas Creek Pazkway, Winston-Salem, NC 27127
Telephone [phone] • Fa�c [phone] • Courier Box 13-12-04

, 2op `NATEqp Office Use Only:
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! ' � �'"��I i, > �
Corps action ID no.
I1st a,. ,� �. o T DWQ project no.
`� ��� Form Version '1.4 January 2009
Pre-Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1 a. Type(s) of approval sought from the Corps: ❑X Section 404 Permit ❑ Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: 3 or General Permit (GP) number:
1 c. Has the NWP or GP number been verified by the Corps? ❑ Yes XD No
1 d. Type(s) of approval sought from the DWQ (check all that apply):
❑ 401 Water Quality Cer[ification — Regular ❑ Non-404 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorization
1 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:
❑X Yes ❑ No ❑ Yes �X No
1f. 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 OX No
or in-lieu fee program.
1 g. Is the project located in any of NC's lwenty coastal counties. If yes, answer 1 h � Yes ❑X No
below.
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ❑ Yes ❑X No
2. Project Information
2a. Name of projed: SR 1945 Rosebud Road
2b. County: Stokes
2c. Nearest municipality / town: Walnut Cove
2d. Subdivision name:
2e. NCDOT only, T.I.P. or state project no:
3. Owner Information
3a. Name(s) on Recorded Deed:
3b. Deed Book and Page No.
3c. Respo�sible Party (for LLC if North Carolina Department of Transportation
applicable):
3d. Street address: 375 Silas Creek Pkwy
3e. City, state, zip: Winston-Salem, North Carolina 27127
3f. Telephone no.: [phone]
3g. Fax no.: [phone]
3h. Email address:
Page � of 10
PCN Form — Version 1.4 January 2009

4. Applicant Information (if different from owner)
4a. Applicant is: X❑ Agent ❑ Other, specify:
4b. Name: Stephanie Braquet
4c. Business name North Carolina Department of TranspoRation
(if applicable):
4d. Street address: 375 Silas Creek Pkwy
4e. City, state, zip: Winston-Salem, NoRh Carolina 27127
4f. Telephone no.: [phone]
4g. Fax no.: [phone]
4h. Email address: [e-mail]
5. Agent/Consultant Information (if applicable)
Sa. Name:
5b. Business name
(if applicable):
Sc. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:
Page 2 of 10

B. Project Information and Prior Project History
1. Property Identifcation
1 a. Property identification no. (tax PIN or parcel ID):
1 b. Site coordinates (in decimal degrees): Latitude: 36.3079 Longitude: -80.1897
1c. Property size: � 1L55 acres
2. Surface Waters
2a. Name of nearest body of water to proposed project: Voss Creek
2b. Water Quality Classification of nearest receiving water: C
2c. River basin: Roanoke
3. 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:
subdivision
3b. List the total estimated acreage of all existing wetlands on the property: 0
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property: 60
3d. Explain the purpose of the proposed project:
The purpose is to replace an under-sized pipe that is causing erosion toward the roadway.
3e. Describe the overall project in detail, including the type of equipment to be used:
The existing pipe is under-sized a�d causing the shoulders to erode back toward the road. NCDOT would like to up-size the pipe and add a headwall u:
0
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the � Yes �X No ❑ Unknown
Corps or State been requested or obtained for this property / Comments:
ro"ect includin all rior hases in the ast?
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 ❑X No ❑ Unknown
this project (including all prior phases) in the past?
Sb. If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
6a. Is this a phased project? ❑ Yes ❑X No
6b. If yes, explain.
Page 3 of 10
PCN Form — Version 1.4 January 2009

C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your projed (check all that apply):
❑ Wetlands ❑X Streams—tributaries ❑ Buffers ❑ Open Waters ❑ Pond Construction
2. Wetland Impacts
If there are wetland 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 ofjurisdiction Area of
number Corps (404,10) or impact
Permanent (P) or DWQ (401, other) (acres)
Tem ora T
W1 - Choose one Choose one Yes/No -
� - Choose one Choose one Yes/No -
�I�/3 - Choose one Choose one Yes/NO -
Wq - Choose one Choose one Yes/No -
W5 - Choose one Choose one Yes/No -
�J�/g - Choose one Choose one Yes/No -
2g. Total Wetland Impacts: 0
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.
3 a. 3 b. 3c. 3d. 3e. 3f. 3g.
Stream impad 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 T Dam constmction Voss Creek PER Corys 3 4
SZ - Choose one - -
S3 - Choose one - -
S4 - Choose one - -
SS - Choose one - -
S6 - Choose one - -
3h. Total stream and tributary impacts 4
3i. Comments:
Page 4 of 10
PCN Form — Version 1.4 January 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 i�dividuall list all o en water im acts 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
Tem ora T
01 - Choose one Choose
pQ - Choose one Choose
03 - Choose one Choose
04 - Choose one Choose
4f. Total open water impacts o
4g. Comments:
5. Pond or Lake Construction
If ond or lake construction ro osed, then com lete the chart below.
Sa. Sb. Sc. Sd. 5e.
Pond ID number Proposed use or Wetland Impads (acres) Stream Impacts (feet) Upland
purpose of pond (acres)
Flooded Filled Excavated Flooded Filled Excavated
p� Choose one
p2 Choose one
Sf. Total: o
Sg. Comments:
5h. Is a dam high hazard permit required? ❑ Yes ❑X No If yes, permit ID no:
5i. Expected pond surface area (acres):
S. Size of pond watershed (acres):
Sk. Method of construdion:
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 an im acts re uire miti ation, then ou MUST fill out Section D of this form.
6a. Project is in which protected basin? ❑ Neuse ❑ Tar-Pamlico ❑ Catawba ❑ Randleman ❑ Other:
6b. 6c. 6d. 6e. 6f. 6g.
Buffer Impact Reason for impad Stream name Buffer Zone 1 Zone 2
number— mitigation impact impact
Permanent (P) or required? (square (square
Tempora T) feet feet
g� - Yes/No
g2 - Yes/No
g3 - Yes/No
g4 - Yes/No
g5 Yes/No
gg - Yes/No
6h. Total Buffer Impacts: 0 0
6i. Comments:
Page 5 of 10

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1 a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
NCDOT is using a headwall which shortens the length of the pipe, thereby impacting less stream-bed.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Using a headwall minimizes the impact to the stream bed and we are not lengthening the pipe.
2. Com ensato Miti ation for Im acts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for ❑ Yes ❑X No
impacts to Waters of the U.S. or Waters of the State?
2b. If yes, mitigation is required by (check all that apply): ❑ DWQ ❑ Corps
❑ Mitigation bank
2c. If yes, which mitigation option will be used for this
project? ❑ Payment to in-lieu fee program
❑ Permittee Responsible Mitigation
3. Com lete if Usin a Miti ation 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. Com lete if Makin a Pa ment to In-lieu Fee Pro ram
4a. Approval letter from in-lieu fee program is attached. ❑ 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. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 6 of 10
PCN Form — Version 1.4 January 2009

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires � yes ❑X 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.g., payment to private mitigation bank,
permittee responsible riparian buffer restoratio�, payment into an approved in-lieu fee fund).
6h. Comments:
Page 7 of 10

E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1 a. Does the projed include or is it adjacent to protected riparian buffers identified � Yes X❑ No
within one of the NC Ri arian Buffer Protection Rules?
1 b. If yes, the� is a diffuse flow plan included? If no, explain why.
� Yes � No
2. Stormwater Mana ement Plan
2a. What is the overall percent imperviousness of this project? p o�o
2b. Does this ro'ect re uire a Stormwater Mana ement Plan? ❑ Yes ❑ No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
N/A because we are not doing any road work, only pipe replacement.
2d. If thfs project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
2e. Who will be responsible for the review of the Stormwater Management Plan?
3. Certified Local Govemment Stortnwater Review
3a. In which local overnmenYs'urisdiction is this ro ect?
❑ Phase II
3b. Which of the following locally-implemented stormwater management programs ❑ NSW
apply (check all that apply): ❑ USMP
� Water Supply Watershed
� Other:
3c. Has the approved Stormwater Management Plan with proof of approval been ❑Yes ❑ No
attached?
4. DWQ Stormwater Pro rem Review
�Coastal counties
❑HQW
4a. Which of the following state-implemented stormwater management programs apply �ORW
(check all that apply): ❑Session Law 2006-246
❑Other:
4b. Has the approved Stormwater Management Plan with proof of approval been � Yes ❑ No
attached?
5. DWQ 401 Unit Stortnwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements? ❑ Yes ❑ No
5b. Have all of the 401 Unit submittal requirements been met? ❑ Yes ❑ No
Page 8 of 10
PCN Form — Version 1.4 January 2009

F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1a. Does the project involve an expenditure of public (federel/state/local) funds or the � yes ❑ No
use of public (federal/state) land?
1 b. 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 ❑ Yes ❑X No
(North Carolina) Environmental Policy Act (NEPAlSEPA)?
1 c. 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
Camments:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards, ❑ Yes ❑X No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b. Is this an after-the-fact permit application? ❑Yes ❑X 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. Will this project (based on past and reasonably anticipated future impacts) result in �yes ❑X 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.
N/A
Page 9 of 10
PCN Form — Version 1.4 January 2009

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
Sa. Will this project occur in or near an area with federally proteded species or � Yes ❑X No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Ad � Yes X� No
impacts?
5c. If yes, indicate the USFWS Field Office you have contaded. -
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
Arc Map and site visit
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? ❑ Yes 0 No
6b. What data sources did you use to determine whether your site would impact Essential Fish Ha6itat?
Arc Map and site visit
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 � yes ❑X 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?
Arc Map and site visit
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain? ❑ Yes ❑X No
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination7
FEMA flood map
Stephanie Braquet /�1 n . 10/21/2014
" W�A
ApplicanUAgenYs Printed Name ApplicanUAgents nature Date
(AgenPS signature is valid onty f an authorization
letter from the applirant s rovided.
Page 10 of 10

APPROVED NRISDICTIONAL DETERMINATION FORM
U.S. Army Corps of Engineers
This form should be comple[ed by following [he instruc[ions provided in Section IV of the JD Form Instructional Guidebook.
SECTION I: BACKGROUND INFORMATION
A. REPORT COMPLETION DATE FOR APPROVED JURISDICTIONAL DETERMINATION (JD): 10l21/Z014
B. DISTRICT OFFICE, FILE NAME, AND NUMBER:
C. PROJECT LOCATION AND BACKGROUND INFORMATION:
State:North Cerolina Counry/parish/borough: Stokes CSty: Walnut Cove
Center coordinates of site ((aUlong in dcgrce decimal format): Lat. 363079° N, Long. -80.1897° W.
Universal"Pransverse Mercator:
Name of neazest waterbody: Sandy Branch
Name of neazest Traditional Navigable Water (TN1� into which the aquatic resource flows: Town Fork Creek
Name of watershed or Hydrologic Unit Code (HUC): Roanoke
� Check if map/diagram of review area and/or potential jurisdictional azeas is/are availablc upon request.
❑ Check if other sites (e.g., offsite mitigation sites, disposal sites, etc...) are associated with this action and aze recorded on a
different JD form.
D. REVIEW PERFORMED FOR SITE EVALUATION (CHECK ALL THAT APPLI�:
❑ Oftice (Desk) Determination. Date:
� Field Determination. Date(s): 10/02/2014
SECTION II: SUMMARY OF FINDINGS
A. RIIA SECTION ]0 DETERMINATION OF JURISDICTION.
There Are no "navigable waters ofthe iLS" within Rivers a�d Hazbors Act (RHA)jurisdiction (as defined by 33 CFR part 329) in the
review area. [ReguiredJ
❑ Waters subject to the ebb and flow of the tide.
❑ Waters aze presently used, or have been used in the past, or may be susceptible for use to transport interstate or foreign commerce.
Explain:
B. CWA SECTION 404 DETERMINAT[ON OF JORISDICTION.
There 4re "waters ofthe US." within Clean Water Act (CWA) jurisdiction (as defined by 33 CFR part 328) in the review area. [RequiredJ
1. Waters of the U.S.
a. Indicate presence of waters of U.S. in review area (check all that apply): �
� TNWs, includingterritorial seas
❑ WetlandsadjaeenttoTNWs
� Relalively permanent watersZ (RPWs) that flow directly or indirectly into TNWs
❑ Non-RPWs that flow directly or indirectly into TNWs
� Wetlands directly abutting RPWs that flow directly or indirectly in[o TNWs
❑ Wetlands adjacent to but not directly ab�tting RPV✓s that flow directly or indirectly into TTIWs
❑ Wetlands adjacent to non-RPWs that flow directly or indirectty into TNWs
❑ Impoundments ofjurisdictional waters
❑ Isolated (intersYate or intrastate) waters, includiug isolated wetlands
b. Identify (eatimate) size of waters of the 0.S. in Yhe review area:
Non-we[land waters: 601ineaz feet: 3wid[h (ft) antUor acres.
Wetlands: 0 acres.
c. Limits (boundaries) of jurisdiction based on: Established by OHR'M.
Elevation ofestablished OHWM (iflmown): .
2. Non-regulated waters/wetlauds (check if applicable):'
❑ Potentiallyjurisdictional waters and/or wetlands were assessed within the review area and determined to be notjurisdictional.
Explain: . �
' Boxes checkcd bclow shall be suppoRed by completing thc appropriate sections in Section III below.
' Fbr purposes of this fonn, an RP W is defined as a tributary that is not a TNW arid that Typically flows year-rou�d or has con[inuous flow at least "seasonally"
(e.g., typically 3 months).
' Supporting documenta[ion is presen[ed in Section IIi.F.

SECTION III: CWA ANALYSIS
A. TNWs AND WETLANDS ADJACENT TO TNWs
The agencies will assert jurisdiction over TNWs and wetlands adjacent to TNWs. If the aquatic resource is a TNW, complete
Section III.A.1 and Section IILD.1. only; if the aquatic resource is a wetland adjacent to a TNW, complete Sections III.A1 and 2
and Section TII.D1.; otherwise, see Sectioo III.B below.
1. TNW
Identify 1'NW:
Summarize rationale suppoRing determination:
2. WetlandadjacenttoTNW
Summarize rationale supporting conclusion that wetland is "adjacenP':
B. CHARACTERISTIC5 OF TRIBUTARY (THAT IS NOT A TNW) AND ITS ADJACENT WETLANDS (IF ANY):
This section summarizes information regarding characteristics of the tributary and its adjacent wetlands, if any, and it helps
determioe whether or not the standards for jurisdictioo established under Rapanashave been met.
The agencies will assert jurisdiction over non-navigable tributaries of TNWs where the tributaries are "relatively permanent
waters" (RPWs), i.e. tributaries that typically flow yearvround or have continuous flow at least seasonally (e.g., typically 3
months). A wetland that directly abuts an RPW is also jurisdictional. If the aquatic resource is not a TNW, but has year-round
(perennial) flow, skip to Section III.D.2. If the aquatic resource is a wetland directly abutting a tributary with pere��ial flow,
skip to Section III.D.4.
A wetland that is adjacent to but that does not directly abut an RPW requires a significant nexus evaluatioa Corps districts and
EPA regions will include in the record any available information that documents the existence oFa significant nexus between a
relatively permanent tributary that is not perennial (and its adjacent wetlands if any) and a traditional navigable water, even
though a significant nexus Tinding is not required as a matter of law.
If the waterbody° is not an RPW, or a wetland directly abutting an RPW, a JD will require additional data to determine if the
waterbody has a significant nexus with a TNW. ISthe tributary has adjacent wetlands, the significant nexus evaluation must
consider the tributary in combination with all of its adjace�t wetlands. This significant nexus evaluation that combines, for
analytical purposes, the tributary and all of its adjacent wetlands is used whether the review area identi£ed in the JD request is
the tributary, or its adjacent wetlands, or both. If the JD covers a Mibutary with adjacent wetlands, complete Section III.B1 for
the tributary, Sectio� III.B.2 for any onsite wetla�ds, and Section III.B.3 for all wetlands adjacent to that tributary, bo[h onsite
and offsite. The determination whether a significant nexus exists is determined in Section III.0 below.
1. Characteristics ot non-TNWs that flow directly or indirectly into TNW
(i) General Area Couditions:
Watershed size: 35acres
Drainage azea: 34 acres
Average annuai rainfall: 4 inches
Average annual snowfall: 3 inches
(ii) Physical Characteristics:
(a) Relatio�shin with TNW:
� Trib�tary flows directly into 7'NW.
❑ Tributery flows Yhrough Pick List tribuCaries befure entering TNW.
Project waters aze i-2 river miles from 7'NW.
Project waters are 1(or less) rive� miles from RPW.
Project waters are 2-5 aerial (straight) miles from TN W.
Projcct waters are 1(ar less) aerial (straight) miles from RPW.
Project waters cross or serve as sffite boundazies. Explain:
Identify flow route to TNWs: the hibutary flows south into Town Fork Creek which flows north into the Dan River..
Tributary stream order, 3fknown: 2.
"NOte that [he InsWC[ional Guidebook contains additional inFortnation regarding swales, di[ches, washes, and erosional feaNres generally and in thc azid
West.
' Flow route can be described by identifying e.g., tributary a, which flows through tk�e review azea, to flow into tributary b, which then flows into 17VW.

(b) General Tributarv Characteristics (check all that apolvl:
Tributary is: � Natural
❑ Artificial (man-made). Explain:
❑ Manipulated (man-altered). Explain:
Tributary properties with respect to top of bank (estimate):
Average width: 3 feet
Average depth: 1 feet
Average side slopes: 21.
Primary hibutary subs[rate composition (check all that apply):
� Silts ❑ Sands ❑ Concrete
❑ Cobbles ❑ Gravel � Muck
❑ Bedrock � Vegetation. Type/%cover: 95
❑ Othcr. Explain: .
Tributary condition/stability [e.g., highly eroding, sloughing banks]. Explain: normal wndition, great stabiliTy.
Presence of mn/riffle/pool complexcs. Explain: no.
Tributary geometry: Relatively straight
Tributary gradient (approximate average slope): 2%
(c) Flow:
Tributary provides for: Intermittent but not seasonal flow
Estimate average number of flow events in review azea/yeaz: 11-20
Describe flow regime: continual.
Other information on doration az�d volume: .
Surface flow is: Confined. Characteristics:
SubsmiacC flow: Uoknown. Explain findiogs:
❑ Dye (or other) test perfoaned: .
Tributary has (check all that apply):
� Bcd and banks
� O[3 WMe (check all indicators thaz apply):
❑ cleaz, natural line impressed on the bank
❑ changes in [he chazacter of soil
❑ shelving
� vegetation matted down, bent, or abscnt
❑ leaf ]itter disturbed or washed away
� sedimen[ deposition
❑ water staiaing
❑ other (list):
❑ Discontinuous OHWM.' Explain:
■
■
■
■
�1
■
■
the presence of litter and debris
destruction of terres[rial vegetatio�
the presence of wrne;k line
sediment sorting
scour
multiple observed or predicted flow events
abrupt change in plant communiry
If factors other than the OHWM were used to determine lateral extent of CWAjurisdiction (check all that apply):
❑ High Tide Line indicaYed by: ❑ Mean High Water Mark i�dicated by:
❑ oil or scum li�e along shore objects ❑ survey to available datum;
❑ fine shell or debris deposits (foreshore) ❑ physical markings;
❑ physical mazkings/chazacteris[ics ❑ vegetation ]ines/changes in vegetation types.
❑ tidal gauges
❑ other (list):
(iii) Chemical Characteristics:
Chazacterize cributary (e.g., water color is clear, discolored, oity film; water quality; general watershed chazactedstics, etc.).
Explain: water is murky and mucky due to presence of cows upstream..
Idcntify specific pollutants, if known: .
6A natural or man-made diswn[inuiTy in ffie OHWM does not necessarily severjurisdic[io� (e.g., where the sheam [emporarily flows underground, or whcrc
the OHWM has been removed by development or agriculNral practices). V✓here there is a break in the OHWM that is mrela[ed to the wa[erbody's flow
regime (e.g., tlow over a rock outcrop or thmugh a culveR), the agencies will look for indicators of flow above and below �he break.
'[bid.

(iv) Biological Characteristics. Channel supports (check all that apply):
❑ Riparian corridoc Chazacteristics (type, average width): .
❑ Wetland fringe. CharacCerisrics: upland and forested.
❑ Habitat for.
❑ Federally Listed species. Explain findi�gs: .
❑ Fish/spawn areas. Explain findings: .
❑ Other environmentally-sensi6ve species. Explain fiudiugs_
❑ Aquatic/wildlife diversity. Explain findings: .
2. Characteristics of wetlands adjacent to non-TNW that flow directly or indirectly into TNW
(i) Physical Characteristics:
(a) General Wetland Characteristics_
Properties:
Wetlnnd size: acres
Wetland type. Explain: .
Wetland qualiTy. Explain: .
Project wctlands cross or scrve as state boundazies. Explain:
(b) General Flow Relationshio with Non-TNW:
Flow is: Pick List. Explain: .
Surface flow is: Pick List
Characteristics:
Subsurface flow: Pick List. Explain findings:
❑ Dye (or other) test performed: .
(c) Wetland Adiacenev Determination with Non-TNVJ:
❑ Directly abutting
❑ Not directly abutting
❑ Discrete wetland hydrologic connection. Explain:
❑ Ecological co�nectioa Explain: .
❑ Scparated by berm/barrier. Explain: .
(d) Proximitv (Relationship) to 7'NW
Pmject wetlands are Pick Liat river miles from 7'N W.
Project waters are Pick List aerial (straight) miles from TNW.
Flow is from: Pick List.
Estimate approximate location of wetland as within the Pick List floodplain.
(ii) Chemical Charecteristics:
Characterize wetland sysfem (e.g., water color is cleaz, brown, oil film on sudace; water quality; general watershed
chazacteristics; etc.). Explain: .
Identify speci5c pollutants, if known: .
(iii) Biological Characteristics. Wetland suppoHs (check all that apply):
❑ Ripazian buffer. Characteristics (type, average width): .
❑ Vegetation type/percent cover. Explain: .
❑ Habitat for:
❑ Federally Listed species. Explain findings: .
❑ Fish/spawn azeas. Explain findings: .
❑ Other environmentally-sensitive species. Explain findings:
❑ Aqoatic/wildlife diversity. Explain findings: .
3. Characteristics of all wetlands adjacent to the tributary (if any)
All wetland(s) being considered in the wmulative analysis: Pick List
Approximately ( ) acres in total aze being considered in the cumulative analysis.

For each wetland, specify the following:
Directiv abuts? (YMl Size (in acresl Direc[ly abuts? (Y/Nl Siu (in accesl
Summarize overal] biological, chemical and physical fw�ctions being performed: .
C. SIGNIFICANT NEXUS DETERMINATION
A significant nexus analysis will assess the flow characteristics and functions of the tributary itself and the functions performed
by any wetlands adjacent to the tributary to determice if they significantly affect the chemical, physical, and biolagical integrity
of a TNW. For each of the following situations, a significant nexus exists if the tributary, in combination with all of its adjacent
wetlands, has more than a speculative or insubstantial effect on the chemical, physical and/or biological integrity of a TNW.
Considerations when evaluating signiLcant �exus include, but are not limited to the volume, duration, and frequency of the flow
of water in the tributary and its proximity to a TNW, and the functions performed by the tributary and all its adjacent
wetlands. It is not appropriate to determine significant nesus based solely on any specific thres6old of distance (e.g. between a
tributary and its adjacent wetland or between a tributary a�d the TNW). Similarly, the fact an adjacent wetland lies withi� or
outside of a Floodplain is not solely determinative of significant nexus.
Draw co�nections between the features documented and the effects on the TNW, as ideotified in the Rapanos Guidance and
discussed in the Instructional Guidebook. Factors to consider include, for example:
• Does the iributary, i� combination with its adjacent wetlands (if any), have the capaciTy to cany polluTants or flood waters to
TNWs, or to reduce the amount of pollutants or flood waters reaching a TNW?
• Does the tributary, in combination with its adjaeent wetlands (if any), provide habitat and lifecycle support functions for fish and
other species, such as feeding, nesYing, spawning, or rearing young for specles that are present in the TTIW?
• Does the tributary, in combination with its adjaeent wetlands (if any), have t6e capacity to transfer nutrients and orgenic earbon that
support downstream foodwebs?
• Does the tributary, in combi�ation with its adjacent wetlands (if any), have other relationships to [he physical, chcmical, or
biological integriry ofthe TNW?
Note: the above list of considerations is not inclusive and other functions observed or known to occur should be documented
below:
1. Significant nexus findings for non-RPW that has no adjacent wetlands and flows directly or indirectly into TNWs. Explain
findings of presence or absence of significant nexus below, based on the tributary itself, then go to Section III.D: .
2. Significant nexus findings for non-RPW and its adjacent wetlands, where the non-RPW ilows directly or indirectly into
TNWs. Explain findings of prese�ce or absence of significant nexus below, based on the tributary i� combinalion with all of its
adjacent wetlands, then go to Seciion IQ.D: .
3. Significant nexus findings for wetlands adjacent to an RPW but that do not direcUy abut the RPW. Explain findings of
presence or absence of significant nexus below, based on the tdbutary in combination with all of its adjacent wetlands, then go to
Section IILD: .
D. DETERMINATIONS OF JURISDICTIONAL FINDINGS. THE SUBJECT WATERS/WETLANDS ARE (CHECK ALL
THAT APPLY):
1. TNWs and Adjacent Wetlands. Check all that apply and provide size estimates iu review erea:
❑ TNWs: linear feel width (ft), Or, acres.
❑ Wetlands adjacentto TTiWs: acres.
2. RPWs that flow directly or indirectly into TNWs.
❑ Tributaries of 1TIWs where tributaries Typically flow yeaz-round arejunsdictionaL Provide data and rationale i�dicating that
tributary is perenriial: .
� Tributaries of'IT1W where tributaries have wntinuous flow "seasonally" (e.g., typically three months cach yeaz) are
jurisdictionaL Data supporting this conclusion is provided at Section III.B. Provide rationale indicating that tributary Rows
seasonally: Area has water at least 3 or more times per yeac.

Provide es[ima[es forjurisdictional waters in the review area (check all Ihat apply):
❑ Tributary waters: linear feet width (ft).
❑ Other non-wetland waters: acres.
Identify type(s) of waters: .
3. Non-RPWss that flow directty or indirecHy into TNWs.
❑ Waterbody that is not a TNW or an RPW, but flows directly or indirectly into a 1'NW, and it has a siguificant nexus wiYh a
TN W isjurisdictional. Data supporting this conclusiou is provided at Section III.C.
Provide estimates for jurisdictional waters wiihin the review area (check al] that apply):
❑ Tributary wa[ers: linear feet width (ti).
❑ Other non-wetland waters: acres.
Ide�tify type(s) of waters: .
4. Wetlands directly abutting an RPW that flow directly or indirectly into TNWs.
❑ Wedands directly abut RPW and thus azejurisdictional as adjacent wetlands.
❑ Wetlands directly abutting an RPW where tributaries rypically flow year-round. Provide data and rationale
indicating that fibutary is perennial in Section III.D2, above. Provide rationale indicating that wetland is
directly abutting an RPW: .
❑ Wetlands directly abutting an RPW where tributaries rypically flow "seasonally." Provide data indicating that tributary is
seasonal in SecCion III.B and rationale in Section III.D2, above. Provide rationale indicating that wetland is direetly
abutting a� RPW: .
Provide acreage estimates for jurisdictional wetla�ds in the review azea: acres.
5. Wetlands adjacent to but not directly abutting an RPW that Flow directly or indirectly into TNWs.
❑ Wetlands that do nol directly abut an RPW, but whe� considered i� combination with the tributary to which they are adjacent
and with similuly situated adjacent wetlands, have a significant nexus with a TNW azejurisidictional. Data supporting this
conclusion is provided at Section IU.C.
Provide acreage estimates forjurisdictional wetlands in the review area: acres.
6. Wetlands adjaceot to non-RPWs that flow directly or iudirectly into TNWs.
❑ Wetlands adjace�t to such waters, and have when considered in combination with the tributary to which they aze adjacent and
with similarly situa[ed adjacent wetlands, 6aue a significant nexus with a TNW are jurisdictional. Data suppor[iug this
coucluston is provided at Section III.C.
Provide estimates for jurisdictional wetlands in the review azea: acres.
7. Impoundments of jurisdictional waters.'
As a general rule, the impoundment of ajurisdictio�al tributary remai�s jurisdictional.
❑ Demonstrate that impoundment was created from "waters of [he U.S.," or
❑ Demonstrate that water meets the criteria for one of the categories presented above (1-6), or
❑ Demonstrate that water is isolated with a nexus to commerce (see E below).
E. ISOLATED �INTERSTATE OR INTRA-STATE] WATER5, INCLUDING ISOLATED WETLANDS, THE USE,
DEGRADATION OR DESTRUCTION OF WHICH COULD AFFECT INTERSTATE COMMERCE, INCLUDING ANY
SUCH WATERS (CHECK ALL THAT APPLl�:10
❑ which are or wuld be used by interstate or foreign travelers for recreational or other purposes.
❑ from which fish or shellfish aze or could be taken and sold in interstate or foreign commerce.
❑ which aze or could be used for indusfial purposes by indush-ies in interstate wmmerce.
❑ Interstate isolated waters. Explain: .
❑ Other faclors. Explain: .
Identify water body and summarize rationale supporting determination:
"See poomote # 3.
' To complete the analysis refer to [he key in Section IILD.6 of the Ins4uctional Guidebook.
10 Prior [o asserting or deelining CWA jurisdiction based solely on this category, Corps Dis[ricts will elevate [6e action ta Corps aod EPA HQ Por
review eonsisten[ wit6 [he process described in the Corps/EPA Memorandum Regarding CWAAcK JurirdicGOn Fol[owingRapanos.

Provide estimates for jurisdictional waters in the review area (check all that apply):
❑ Tributary waters: lineaz feet width (ft).
❑ Other no�-wctland waters: acres.
Identify type(s) of waters: .
❑ WeUands: acres.
F. NON-JURISDICTIONAL WATERS, INCLUDING WETLANDS (CHECK ALL THAT APPLI�:
❑ If potential wetlands were assessed within ihe review azea, these azeas did not meet the criteria in the 1987 Corps of Enginecrs
Wetland Delineation Manual and/or appropriate Regional Supplements.
❑ Review area i�cluded isolated waters with �o substaritial nexus to Ioterstate (or foreig�) commcrce.
❑ Prior to the Jan 2001 Supreme Court decision in "SWANCC,° the review azea would have been regulated based solelv on the
"Migratory Bird Rule" (MBR).
❑ Waters do not meet the "Significant Nex�s° standard, where such a finding is required forjurisdictioa Cxplain: .
❑ Other. (explaiq if not covered above): .
Provide acreage estimates for non jurisdictional waters in Ihe review area, where ffie sole potential basis ofjurisdiction is the MBR
factors (i.e., presence of migratory birds, presence of endangered species, use of water for irrigated agriculture), using bes[ professional
judgmenY (check all that apply):
❑ Non-wetland waters (.e., rivers, streams): linear feet width (ft).
❑ Lakes/ponds: acres.
❑ Other non-wetland waters: acres. List type of aqualic resource: .
❑ Wetlands: aeres.
Provide acreage estimates for non jurisdictional waters in the review area that do not meet the "SiguiScant Nex�s° standazd, where sueh
a finding is required for jurisdietion (check all that apply):
❑ Non-wetland waters (i.e., rivers, streams): linear feet, width (ft).
❑ Lakes/ponds: aeres.
❑ Other non-wetland waters: acres. List type of aquatic resource: .
❑ Wetlands: acres.
SECTION IV: DATA SOURCES.
A. SUPPORTING DATA. Data reviewed for JD (check all that apply - checked items shall be included in case file and, where checked
and reques[ed, appropriately reference sources below):
� Maps, plans, plots or plat submitted by or o� behalf of the applicanUconsultant: .
❑ Data sheets prepared/submitted by or on behalf of ihe applicanUconsultant.
❑ Office concurs with data shects/delineation report.
❑ Office does not concur with data sheets/delineation report.
❑ Data sheets prepared by the Corps: .
❑ Corps navigable waters' study: .
❑ U.S. Geological Survey Hydrologic Atlas: .
❑ USGS NHD data.
❑ USGS 8 and 12 digi[ HUC maps.
� U.S. Geological Survey map(s). Cite scale & quad name:l inch equals 2000 feet/Walnut Cove.
❑ USDA Natural Resources Conservation Seroice Soi] Survey. Citation: .
❑ National wetlands imentory map(s). Cite �ame: .
❑ State/Local wetland inventory map(s): .
❑ FEMA/FIRM maps: .
❑ 100-yeaz Floodplain Elevation is: (Nationa] Geodec[fe Vertical Dat�m oF 1929)
❑ Photographs: ❑ Aerial (Name & Date): .
or � Other (Name & Date): .
❑ Previous determination(s). File no. and date of response ]etter. .
❑ Applicable/supporting case law: .
❑ Applicable/supporting scientific literature: .
� Other information (please spccify)_site review.
B. ADDTTIONAL COMMENTS TO SUPPORT JD:

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Construction Sequence — Pipe to Pipe: SR 1945 Rosebud Rd. — Stokes County
1. Close road.
2. Install erosion control devices at each quadrant.
3. Block upstream flow with impervious structure. Pump azound or pipe azound and
dewater work area if necessary.
4. Remove road fill and pipe.
5. Install footing for headwall
6. Excavate to sufficient depth to allow l foot (or 20 percent) burial of pipe, if no
bedrock is encountered, and install pipe.
7. Backfill pipes and place rip rap for stabilization, and vegetate.
8. Construct
9. Repair stream and bank at inlet end and remove class 1 riprap from outlet end of pipe.
10. Remove impervious dike and a11ow water to flow through new pipe culvert.
11. Notify landscape department for final seeding and mulching.
12. Pave roadway.
13. Site conditions and weather may alter these plans.
14. Construction time expected to be 2 weeks.
15. If there are any questions, call Mr. Daniel Home, Stokes County Maintenance
Engineer at 336-593-8541.

`
SFt 19q5 Rase6ud Raad –Stokes County
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5'Shoulder pavement Width 18' S' 5houlder
PlanView
EP CL EP
Existing Pipe=
F�ro�ased= 48"cm�
Cover=l'min.
prawn by DSM
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Skew=JS° � Sandbags&f�lastic
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Cor�struction Plans for Pipe Replacement
County= Stakes / SR1445 liosebud Road
drawing 1 at z

Single Pi�e Replacerrient
Size 4$" CMp
Pipe Laid 1
NCDDT Division 9
Stokes Covnty
Rosebud Road SR1945
EC Plans for Pipe Repfa[ement
County = Stakes
Name� Rosehud Raad SR 19A5
Or,�tivin� Z bf 2