20190109 Ver 2_Pre-Construction Notification (PCN) Form (6)_20221110

Pre-Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
September 29, 2018 Ver 3
Please note: fields marked with a red asterisk * below are required. You will not be able to submit the form until all mandatory questions are answered.
Also, if at any point you wish to print a copy of the E-PCN, all you need to do is right-click on the document and you can print a copy of the form.
Below is a link to the online help file.
https://edocs.deq.nc.gov/WaterResources/0/edoc/624704/PCN%20Help%20File%202018-1-30.pdf
County (or Countie s) whe re the proje ct is locate d:*
Is this proje ct a public transportation proje ct?*
Is this a NCDOT Proje ct?*
(NCDOT only) T.I.P. or state proje ct numbe r:
WBS #*
1a. Type(s) of approv al sought from the Corps:*
1b. What type (s) of permit(s) do you wish to se e k authorization?*
This form may be used to initiate the standard/individual permit process with the Corps. Please contact your Corps representative concerning submittals for standard permits. All required items that
are not provided in the E-PCN can be added to the miscellaneous upload area located at the bottom of this form.
1c. Has the NWP or GP numbe r be e n v e rifie d by the Corps?*
Nationwide Pe rmit (NWP) Numbe r:
NWP Numbe rs (for multiple NWPS):
1d. Type (s) of approv al sought from the DWR:*
1e . Is this notification sole ly for the record be cause writte n approv al is not re quire d?
*
For the re cord only for DWR 401 Certification:
For the re cord only for Corps Pe rmit:
1f. Is this an afte r-the -fact pe rmit application?*
A. Processing Information
Wake
Yes No
This is any publicly funded by municipal,state or federal funds road, rail, airport transportation project.
Yes No
B-5326
46040.1.1
(for NCDOT use only)
Section 404 Permit (wetlands, streams and waters, Clean Water Act)
Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
Nationwide Permit (NWP)
Regional General Permit (RGP)
Standard (IP)
Yes No
03 - Maintenance
List all NW numbers you are applying for not on the drop dow n list.
check all that apply
401 Water Quality Certification - Regular 401 Water Quality Certification - Express
Non-404 Jurisdictional General Permit Riparian Buffer Authorization
Individual Permit
Yes No
Yes No
Yes No
1g. Is payme nt into a mitigation bank or in-lie u fe e program propose d for mitigation of impacts?
Acce ptance Le tte r Attachme nt
1h. Is the proje ct locate d in any of NC's twe nty coastal countie s?*
1j. Is the proje ct locate d in a de signate d trout wate rshe d?*
Link to trout information: http://www.saw.usace.army.mil/Missions/Regulatory-Permit-Program/Agency-Coordination/Trout.aspx
1a. Who is the Primary Contact?*
1b. Primary Contact Email:*
1c. Primary Contact Phone :*
1d. Who is applying for the pe rmit?*
1e . Is the re an Age nt/Consultant for this proje ct?*
2. Owner Information
1a. Name of proje ct:*
1b. Subdiv ision name :
1c. Ne arest municipality / town:*
If so, attach the acceptance letter from mitigation bank or in-lieu fee program.
Yes No
Click the upload button or drag and drop files here to attach document
FILE TYPE MUST BE PDF
Yes No
Yes No
B. Applicant Information
NCDOT
[e-mail]
(xxx)xxx-xxxx
[phone]
Owner Applicant (other than owner)
(Check all that apply)
Yes No
2a. Name (s) on re corde d de e d:*
2b. De e d book and page no.:
2c. Re sponsible party:
2d. Addre ss *
2e . Te le phone Numbe r:*
2f. Fax Numbe r:
2g. Email Addre ss:*
NCDOT
(for Corporations)
City
Raleigh
State / Province / Region
NC
Postal / Zip Code
27610
Country
USA
Street Address
1000 Birch Ridge Road
Address Line 2
(xxx)xxx-xxxx
[phone]
(xxx)xxx-xxxx
[e-mail]
C. Project Information and Prior Project Hi story
1. Project Information
B-5326 Bridge 247 over White Oak Creek on SR 2555 Raynor Rd. (Central)
(if appropriate)
Garner
2. Project Identification
2a. Property Ide ntification Numbe r:2b. Prope rty size :
2c. Proje ct Addre ss
2d. Site coordinate s in de cimal de grees
Please collect site coordinates in decimal degrees. Use between 4-6 digits (unless you are using a survey-grade GPS device) after the decimal place as appropriate, based on how the location was
determined. (For example, most mobile phones with GPS provide locational precision in decimal degrees to map coordinates to 5 or 6 digits after the decimal place.)
Latitude:*Longitude:*
3. Surface Waters
3a. Name of the ne are st body of wate r to propose d project:*
3b. Wate r Re source s Classification of ne are st re ce iving wate r:*
Surface Water Lookup
3c. What riv e r basin(s) is your proje ct locate d in?*
3d. Ple ase prov ide the 12-digit HUC in which the project is locate d.*
River Bas in Lookup
4. Project Description and History
4a. De scribe the e xisting conditions on the site and the ge ne ral land use in the v icinity of the proje ct at the time of this application:*
4b. Hav e Corps pe rmits or DWR ce rtifications be e n obtaine d for this proje ct (including all prior phase s) in the past?*
4d. Attach an 8 1/2 X 11 e xce rpt from the most re ce nt v e rsion of the USGS topographic map indicating the location of the proje ct site . (for DWR)
4e . Attach an 8 1/2 X 11 e xce rpt from the most re ce nt v e rsion of the publishe d County NRCS Soil Surve y map de picting the proje ct site . (for DWR)
4f. List the total e stimate d acre age of all e xisting we tlands on the prope rty:
4g. List the total e stimate d line ar feet of all e xisting stre ams on the prope rty:
4h. Explain the purpose of the proposed proje ct:*
4i. Describe the ov e rall proje ct in detail, including indire ct impacts and the type of e quipme nt to be use d:*
4j. Ple ase upload proje ct drawings for the propose d proje ct.
5. Jurisdictional Determinations
5a. Hav e the we tlands or stre ams be e n de line ate d on the prope rty or propose d impact are as?*
Comme nts:
(tax PIN or parcel ID)(in acres)
City State / Province / Region
Postal / Zip Code Country
Street Address
Address Line 2
35.671817
ex: 34.208504
-78.548724
-77.796371
White Oak Creek
C, NSW
Neuse
030202011003
Land use is comprised of a mix of residential, commercial, industrial, and wooded communities.
Yes No Unknown
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File type must be pdf
Click the upload button or drag and drop files here to attach document
File type must be pdf
0.5 acre
(intermittent and perennial)
500 linear feet
To replace a functionally obsolete and structurally deficient bridge.
The project involves replacing a 36-foot, two span bridge with a 150-foot, three span bridge on existing alignment using an on-site detour. Standard road building equipment, such as
trucks, dozers, and cranes will be used.
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File type must be pdf
Yes No Unknown
5b. If the Corps made a jurisdictional de termination, what type of dete rmination was made ?*
Corps AID Numbe r:
5c. If 5a is ye s, who de line ate d the jurisdictional are as?
Name (if known):
Age ncy/Consultant Company:
Othe r:
5d. List the date s of the Corp jurisdiction de te rmination or State de te rmination if a de te rmination was made by the Corps or DWR.
5d1. Jurisdictional de te rmination upload
6. Future Project Plans
6a. Is this a phase d proje ct?*
Are any othe r NWP(s), re gional ge ne ral pe rmit(s), or indiv idual pe rmits(s) use d, or inte nde d to be use d, to authorize any part of the propose d proje ct or relate d activ ity? This
include s othe r se parate and distant crossing for linear proje cts that re quire De partment of the Army authorization but don’t re quire pre -construction notification.
1. Impacts Summary
1a. Whe re are the impacts associate d with your proje ct? (che ck all that apply):
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
"W." will be use d in the table be low to re pre se nt the word "we tland".
2a. Site #*(?)2a1 Re ason *(?)2b. Impact type *(?)2c. Type of W.*2d. W. name *2e . Fore ste d *2f. Type of
Jurisdicition *(?)
2g. Impact
are a *
2g. Total Te mporary We tland Impact
2g. Total Pe rmane nt We tland Impact
2g. Total We tland Impact
2h. Comme nts:
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this question for all stream sites impacted.
"S." will be used in the table below to represent the word "stream".
3a. Re ason for impact *(?)3b.Impact type *3c. Type of impact *3d. S. name *3e . Stre am Type *
(?)
3f. Type of
Jurisdiction *
3g. S. width *3h. Impact
le ngth *
S1
Preliminary Approved Not Verified Unknown N/A
Example: SAW-2017-99999
SAW-2013-01348
Jason Dilday
NCDOT
USACE PJD dated 7/26/2013
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B5326PJD.pdf 13.44MB
File type must be PDF
Yes No
D. Proposed Impacts Inventory
Wetlands Streams-tributaries Buffers
Open Waters Pond Construction
1a Fill/Mech. Clearing P Bottomland Hardwood Forest WA Yes Corps 0.001
(acres)
1b Fill/Mech. Clearing P Bottomland Hardwood Forest WA Yes Corps 0.090
(acres)
0.000
0.091
0.091
Impacts to wetland from 1a total less than 0.01 ac. combined.
riprap at embankment Permanent Bank Stabilization White Oak Creek Perennial Both 36
Average (feet)
19
(linear feet)
S2
S3
S4
S5
S6
** All Perennial or Intermittent streams must be verified by DWR or delegated local government.
3i. Total jurisdictional ditch impact in square fe e t:
3i. Total pe rmane nt stre am impacts:
3i. Total te mporary stream impacts:
3i. Total stre am and ditch impacts:
3j. Comme nts:
6. Buffer Impacts (for DWR)
If project will impact a protected riparian buffer, then complete the chart below. Individually list all buffer impacts below.
6a. Proje ct is in which prote ct basin(s)?*
6b. Impact Type *(?)6c. Per or Te mp *(?)6d. Stre am name *6e . Buffe r mitigation re quire d?*6f. Zone 1 impact *6g. Zone 2 impact *
6h. Total buffer impacts:
Zone 1 Zone 2
Total Te mporary impacts:
Zone 1 Zone 2
Total Pe rmane nt impacts:
Zone 1 Zone 2
Total combine d buffe r impacts:
riprap at embankment Permanent Bank Stabilization White Oak Creek Perennial Both 36
Average (feet)
26
(linear feet)
riprap at embankment Temporary Bank Stabilization White Oak Creek Perennial Both 36
Average (feet)
5
(linear feet)
bridge pier removal Temporary Dewatering White Oak Creek Perennial Both 36
Average (feet)
25
(linear feet)
riprap at embankment Permanent Bank Stabilization White Oak Creek Perennial Both 36
Average (feet)
135
(linear feet)
riprap at embankment Temporary Bank Stabilization White Oak Creek Perennial Both 36
Average (feet)
5
(linear feet)
0
180
35
215
Check all that apply.
Neuse Tar-Pamlico
Catawba Randleman
Goose Creek Jordan Lake
Other
1a-Fill/Clearing-Parallel P SA Yes 775
(square feet)
4,372
(square feet)
1b-Fill/Clearing-Road Crossing P White Oak Creek No 576
(square feet)
1,255
(square feet)
1c-Fill/Clearing-Road Crossing P White Oak Creek No 0
(square feet)
15
(square feet)
1d-Fill/Clearing-Road Crossing P White Oak Creek No 1,746
(square feet)
1,416
(square feet)
1e-Fill/Clearing-Bridge P White Oak Creek No 1,121
(square feet)
0
(square feet)
1f-Fill/Clearing-Bridge P White Oak Creek No 2,316
(square feet)
1,273
(square feet)
1g-Fill/Clearing-Bridge P White Oak Creek No 2,352
(square feet)
1,473
(square feet)
1h-Fill/Clearing-Bridge P White Oak Creek No 1,016
(square feet)
0
(square feet)
0.00 0.00
9,902.00 9,804.00
9,902.00 9,804.00
6i. Comme nts:
Supporting Docume ntation - i.e . Impact M aps, Plan She e t, e tc.
1. Avoidance and Minimization
1a. Spe cifically de scribe me asure s take n to av oid or minimize the propose d impacts in de signing the proje ct:*
1b. Spe cifically de scribe me asure s take n to av oid or minimize the propose d impacts through construction te chnique s:*
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Doe s the proje ct re quire Compe nsatory M itigation for impacts to Wate rs of the U.S. or Waters of the State ?
2b. If this proje ct DOES NOT re quire Compe nsatory M itigation, e xplain why:
NC Stream Temperature Classification Maps can be found under the Mitigation Concepts tab on the Wilmington District's RIBITS website.
*** Recent changes to the stormwater rules have required updates to this section .***
1. Diffuse Flow Plan
1a. Doe s the proje ct include or is it adjace nt to protecte d riparian buffe rs ide ntifie d within one of the NC Riparian Buffe r Prote ction Rule s?
1b. All buffe r impacts and high ground impacts re quire diffuse flow or othe r form of stormwate r tre atme nt. If the proje ct is subject to a state imple me nte d riparian buffe r prote ction
program, include a plan that fully docume nts how diffuse flow will be maintaine d.
All Stormwate r Control M e asure s (SCM )s must be de signe d in accordance with the NC Stormwate r De sign M anual. Associate d supple me nt forms and othe r docume ntation shall be
prov ide d.
What type of SCM are you prov iding?
For a list of options to meet the diffuse flow requirements, click here.
Diffuse Flow Docume ntation
2. Stormw ater Management Plan
2a. Is this a NCDOT proje ct subje ct to compliance with NCDOT’s Indiv idual NPDES pe rmit NCS000250?*
2b. Doe s this proje ct meet the re quire me nts for low de nsity proje cts as de fine d in 15A NCAC 02H .1003(2)?*
To look up low density requirement click here 15A NCAC 02H .1003(2).
Comme nts:
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B5326_Permit_Drawings_20190122.pdf 5.08MB
B5326_Permit_Drawings_Buffer_20190122.pdf 2.66MB
B5326_Roadway.pdf 2.71MB
File must be PDF
E. Impact Justification and Mitigation
NCDOT Design Standards in Sensitive Watersheds will be employed. See Stormwater Management Plan for additional measures.
The replacement structure will not have deck drains. All bridge drainage will discharge outside of the buffers. Velocities of stormwater are reduced to
non-erosive flows through the use of riprap pads and 'V' ditches. 2:1 slopes will be used in wetlands.
Yes No
Impacts to jurisdictional streams and wetlands within the project area do not require mitigation. Permanent impacts to streams are due to bank stabilization and do not require mitigation.
Permanent impacts to wetlands are less than 0.1 acre. Mitigation is required for buffer impacts.
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
Yes No
Level Spreader
Vegetated Conveyance (lower SHWT)
Wetland Swale (higher SHWT)
Other SCM that removes minimum 30% nitrogen
Proposed project will not create concentrated stormwater flow through the buffer
(check all that apply)
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File type must be PDF
Yes No
Yes No
1. Environmental Documentation
1a. Doe s the proje ct inv olv e an e xpe nditure of public (fe de ral/state /local) funds or the use of public (fe de ral/state ) land?*
1b. If you answe re d “ye s” to the abov e , doe s the proje ct re quire pre paration of an e nv ironme ntal docume nt pursuant to the re quire me nts of the National or State (North Carolina)
Env ironme ntal Policy Act (NEPA/SEPA)?*
1c. If you answe re d “ye s” to the abov e , has the docume nt re v ie w be e n finalize d by the State Cle aring House ? (If so, attach a copy of the NEPA or SEPA final approv al le tte r.)*
NEPA or SEPA Final Approv al Le tte r
2. Violations (DWR Requirement)
2a. Is the site in v iolation of DWR Wate r Quality Ce rtification Rule s (15A NCAC 2H .0500), Isolate d We tland Rule s (15A NCAC 2H .1300), or DWR Surface Wate r or We tland Standards or
Riparian Buffe r Rule s (15A NCAC 2B .0200)?*
3. Cumulative Impacts (DWR Requirement)
3a. Will this proje ct (base d on past and re asonably anticipate d future impacts) re sult in additional de v e lopme nt, which could impact ne arby downstre am water quality?*
3b. If you answe re d “no,” prov ide a short narrativ e description.
4. Sew age Disposal (DWR Requirement)
4a. Is sewage disposal re quire d by DWR for this proje ct?*
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this proje ct occur in or ne ar an are a with fe de rally prote cte d spe cie s or habitat?*
5b. Hav e you che cke d with the USFWS conce rning Endange re d Specie s Act impacts?*
5c. If ye s, indicate the USFWS Fie ld Office you hav e contacte d.
5d. Is anothe r Fe de ral age ncy inv olved?*
5e . Is this a DOT proje ct locate d within Div ision's 1-8?*
5j. What data source s did you use to de te rmine whe the r your site would impact Endange re d Spe cie s or De signate d Critical Habitat?*
Consultation Docume ntation Upload
6. Essential Fish Habitat (Corps Requirement)
6a. Will this proje ct occur in or ne ar an are a de signate d as an Esse ntial Fish Habitat?*
6b. What data source s did you use to de te rmine whe the r your site would impact an Esse ntial Fish Habitat?*
G. Supplementary Information
Yes No
Yes No
Yes No
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FILE TYPE MUST BE PDF
Yes No
Yes No
Due to the minimal transportation impact resulting from this bridge replacement, this project will neither influence nearby land uses nor stimulate
growth. Therefore, a detailed indirect or cumulative effects study will not be necessary.
Yes No N/A
Yes No
Yes No
Raleigh
Yes No Unknown
Yes No
N.C. Natural Heritage Program database; USFWS-Raleigh Field Office website; biological surveys for protected species listed for Wake County, which
include red-cockaded woodpecker (RCW), dwarf wedgemussel, Tar River spinymussel, yellow lance, Cape Fear shiner and Michaux's sumac. The
species received biological conclusions of "No Effect". No habitat is present for RCW, Cape Fear shiner, or the three listed mussels. Habitat for
Michaux's sumac exists, however no specimens were observed during a 9/22/2017 survey. There were no bald eagles or nest observed within 660
feet of the project area on 9/22/2017. PBO for Nothern Long Eared bat.
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File type must be PDF
Yes No
NMFS County Index
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 proje ct occur in or ne ar an are a that the state , fe de ral or tribal gov ernments hav e de signate d as hav ing historic or cultural pre se rv ation status (e .g., National Historic
Trust de signation or propertie s significant in North Carolina history and archae ology)?*
7b. What data source s did you use to de te rmine whe the r your site would impact historic or arche ological re source s?*
7c. Historic or Pre historic Information Upload
8. Flood Zone Designation (Corps Requirement)
Link to the FEM A Floodplain M aps: https://msc.fema.gov/portal/search
8a. Will this proje ct occur in a FEM A-de signate d 100-ye ar floodplain?*
8b. If ye s, e xplain how proje ct me e ts FEM A re quire me nts:
8c. What source (s) did you use to make the floodplain de te rmination?*
Comme nts
M isce llane ous attachments not previously re que ste d.
*
I have given true, accurate, and complete information on this form;
I agree that submission of this PCN form is a “transaction” subject to Chapter 66, Article 40 of the NC General Statutes (the “Uniform Electronic Transactions Act”);
I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes (the “Uniform Electronic Transactions Act”);
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature; AND
I intend to electronically sign and submit the PCN form.
Full Name :*
Signature
Date
Yes No
NEPA Documentation
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File must be PDF
Yes No
NCDOT Hydraulics Unit coordination with FEMA
FEMA Maps
Miscellaneous
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TalecrisB-5326.pdf 126.75KB
File must be PDF or KMZ
Si gnature
By checking the box and signing below, I certify that:
Mack Christopher Rivenbark, III
1/24/2019