20150368 Ver 1_Application_20150416

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STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATTON
PAT MCCRORY ANTHONY J. TATA
GOVERNOR SECRETARY
April 16, 2015
US Army Corps of Engineers NC Division of Water Resources
Raleigh Regulatory Field Office Winston-Salem Regional Ofiice
Attn: Mr. David Bailey Attn: Mr. Dave Wanucha
3331 Heritage Trade Dr, Ste. 105 585 Waughtown St.
Wake Forest, NC 27587 Winston-Salem, NC 27107
Subject: Nationwide 14 Permit Application for the Replacement of Bridge No. 53 on SR 1527
(River Bend Road) over Cane Creek, Caswell CounTy, North Carolina, WBS Element No.
17BP.7.R.82
Dear Mr. Bailey and Mr. Wanucha:
The North Carolina Department of Transportation (NCDOT) is proposing to replace the subject bridge.
The purpose of the project is to replace a functionally obsolete 69' L x 20' W three span timber bridge
with a new 105' L x 30' W, single span box beam bridge. An on-site detour will be used to convey
traffic during construction because an off-site detour would by necessity route travelers into Virgina
and that was not a viable option. The detour bridge will be a 80 ft. L x 26 ft. W bridge. The project
will also include some minor approach work on the existing roadway.
The North Carolina Natural Heritage Database was checked for records of threatened and endangered
species. A survey for James spiuymussel species and habitat was conducted and a"No EffecY'
biological conclusion was rendered. Mr. Gary Jordan concurred with this assessment. The Bald eagle
is protected in every county in North Carolina under the Bald and Golden Eagle Protection Act. No
suitable feeding/water source is located witl�in one mile of the project study area to support Bald eagle
habitat. Further, Mr. Gary Jordan (USFWS) recently released the Programmatic Conference Opinion
(PCO) for the recently listed Northem Long Eared Bat (NLEB). This opinion, states in part, that "... it
is the Service's corrference opiraion that NCDOT activities i�a eastern tVorth CardiJaa (Divisions 1-8), as
pr•oposed, are not likely to jeopaNdize the coiatinued existence of the NLEB. "
This project was reviewed by NCDOT's Auman Environment Unit in 2010 and 2013 for potential
affects to historical architecture and archaeology. It was determined there would be no eligible
architectura( or u•chaeological resources present within the project study area.
The project study area is comprised of a mix of hardwood forest the majority of the surrounding
landscape being agricultural/sivaculh�ral operations. There are 2 wetlands within the project study
area; one on the nortli and one on the south side of the existing bridge. Botl� wetland areas are
contained witliin active cow patures.
NCDOT best management practices (BMPs) will be used to minimize and control sedimentation and
erosion. The construction foremau will review the BMPs daily to ensure erosion and sedimentation is

Bridge No. 53 Page 2 April 16, 2015
being effectively controlled. If the foreman determines the devices are not functioning as intended,
they will be replaced immediately with better devices.
Impacts to Waters of the United States
Cane Creek (DWR Class: WS-N) is shown on the USGS topographic map as a perennial stream. The
channel is well defined with a substrate primarily coinposed of sand, silt, aud gravel and is
approximately 30-40 feet in width. From the project site, Beaver Creek flows south to its confluence
with the Dan River. The Dan River meets the definition of a Traditional Navigable Water. For these
reasons, we believe Cane Creek is a Relatively Permanent Water and is under the jurisdiction of the
U.S. Ai2ny Corps of Engineers. In order to construct the project, it will be necessary to impact waters
of the United States in the Roanoke River Basin (HLJC 03010104). Specifically, NCDOT is requesting
to replace Bridge No. 53 with a new, longer bridge. The impacts are listed in the table below:
Perm.
Perm. Temp. Temp. Temp. Fill
Existing Hand
Structure Size / SW SW Channel �xisting in Clearing in
Type Impacts Impacts Cl�annel Wetlands
(ac) ( ac) Impacts Impacts (tt) (ac) �'etlands (ac)
Streambank
stabilization, 0.02 0.01 75 20 0.02 0.04
temporary onsite
detour
Permits Requested
NCDOT is hereby requesting authorization under Section 404 of the Clean Water Act to proceed with
the construction project outlined above. We are also requesting authorization under Seetion 401 oftl�e
Clean Water Act from the North Carolina Department of Environment and Natural Resources (DENR),
Division of Water Resources (DWR).
If you have any questious or ueed additional information, please contact Jerry Pu•ker at [phone]
or joarker e,ncdot o�v. Your review and consideration are greatly appreciated.
Sincerely,
J.M�ills, PE
Div ion Engineer, Division 7
Enclosures
cc: Tim Powers, NCDOT
Barry Harrington, Roadside Env'sonmental Field Operations Engineer, NCDOT
Jeremy Warren, NCDOT
Bobby No�ris, District 3 Engineer, NCDOT
File Copy

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Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Pre-Construction Notification PCN Form
A. A licant Information
1. Processing
1a. Type(s) of approval sought from the
� Section 404 Permit ❑ Section 10 Permit
Corps:
1 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? � Yes ❑ No
1d. Type(s) of approval sought from the DWQ (check all that apply):
� 401 Water Quality Certification — 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 401 For the record only for Corps Permit:
because written approval is not required? Certification:
❑ Yes � No ❑ Yes � No
1f. Is payment into a mitigation bank or in-lieu fee program proposed for mitigation � yes � No
of impacts? If so, attach the acceptance Ietter from mitigation bank or in-lieu
fee program.
1 g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h ❑ Yes � No
below.
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ❑ Yes � No
2. Project Information
2a. Name of project: Replace Bridge No. 53 on SR 1527 (River Bend Road) over Cane Creek
2b. County: Alamance
2c. Nearestmunicipality/town: Burlington
2d. Subdivision name: N/A
2e. NCDOT only, T.I.P. or state WgS Element No. 17BP.7.R.82
project no:
3. Owner Information
3a. Name(s) on Recorded Deed: North Carolina Department of Transportation
3b. Deed Book and Page No. N/A
3c. Responsible Party (for LLC if Division Engineer NC DOT Division 7, Mr. Mike Mills, PE
applicable):
3d. Street address: PO Box 14996
3e. City, state, zip: Greensboro, NC 27415
3f. Telephone no.: (336) 3343297
3g. Fax no.: [phone]
3h. Email address: [e-mail]
Page 1 of 11
PCN Form — Version 1.3 December 10, 2008 Version

4. Applicant Information (if different from owner)
4a. Applicant is: ❑ Agent � Other, specify: NC DOT Highway Division 7
4b. Nam�: Division Engineer NC DOT Division 7, Mr. Mike Mills, PE
4c. Business name NC DOT
(if applicable):
4d. Street address: PO Box 14996
4e. City, state, zip: Greensboro, NC 27415
4f. Telephone no.: [phone]
4g. Fax no.: [phone]
4h. Email address: [e-mail] *nofe: please a/so copy Mr. JerryParker, HighwayDivision 7Environmenfal
Supervisor on al! correspondence -%parker a�cdotgov
5. AgenUConsultant Information (if applicable)
5a. Name: Mr. Jerry Parker
5b. Business name NC DOT Highway Division 7, Division Environmental Supervisor
(if applicable):
5c. Street address: PO Box 14996
5d. City, state, zip: Greensboro, NC 27415
5e. Telephone no.: [phone]
5f. Fax no.: [phone]
5g. Email address: [e-mail]
Page 2 of 11
PCN Form - Version 1.3 December 10, 2008 Version

B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID): N!A
1 b. Site coordinates (in decimal degrees): Latitude 36.54078 Longitude: -79.26311
(DD.DDDDDD) (-DD.DDDDDD)
1c. Property size: N/A acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to Cane Creek
proposed project:
2b. Water Quality Classification of nearest receiving water: WS-IV; 25-54; 03-02-04
2c. River basin: Roanoke (HUC 03010104)
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:
The project study area is comprised of a mix of hardwood forest with the majority of the surrounding landscape being
agricultural/sivacultural operations. There are 2 wetlands located with the project study area; one on the north and one
on the south side of the existing bridge. Wetland data, upland data and Rapanos forms are attached. Both wetland areas
are contained within active cow pastures and therefore, are mostly comprised of herbs/grasses with a few immature
woody plant stands. A minor amount of temporary wetland impact is necessary for the construction of the onsite detour
during the bridge replacement.
3b. List the total estimated acreage of all existing wetlands on the property:
— 1 acre within project study area
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
3d. Explain the purpose of the proposed project:
To replace a structurally deficient and functionally obsolete timber bridge.
3e. Describe the overall project in detail, including the type of equipment to be used:
Traffic will be detoured on-site due to the fact that the off-site detour would route people into Virginia which was not a viable option.
The temporary detour will be an 80 ft. L X 26 ft. W bridge. Erosion and sedimentation control measures will be installed. The old,
three-span, 69 ft. L X 20 ft. W bridge on timber deck with timber joists and timber abutments will be removed. The proposed
structure will be replaced on its existing alignment. The new bridge will be a single span, 105 ft. L X 30 ft. W box beam. There will be
no deck drains on the new bridge. Storm water will conveyed via existing ditches. Equipment to be used includes a track hoe, dump
truck, avin e ui ment, um s and various hand tools.
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property / � yes ❑ No ❑ Unknown
project (including all prior phases) in the past?
Comments: N/A
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: Arcadis
Name (if known): Mr. Robert Lepsic Other: N/A
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
Wetlahd data forms, upland data forms and Rapanos forms are attached to this submittal.
5. Project History
5a. Have permits or certifications been requested or obtained for � Yes � No ❑ Unknown
this project (including all prior phases) in the past?
5b. If yes, explain in detail according to "help file" instructions.
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PCN Form — Version 1.3 December 10, 2008 Version

6. Future Project Plans
6a. Is this a phased project? ❑ Yes � No
6b. If yes, explain.
N/A
C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for 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, then complete this question for each wetland area impacted.
2a. 2b. 2c. 2d. 2e. 2f.
Wetland impact Type of jurisdiction
number- Type of impact Type of wetland Forested (Corps - 404, 10 Area of impact
Permanent (P) or (if known) DWQ - non-404, other) (acres)
Tem orar T
Temporary Fill ❑ Yes � Corps 0.02
W1 ❑ P� T (Detour) Riparian � No ❑ DWQ
2g. Total wetland lmpacts 0.02
2h. Comments: In addition to the temporary wetland impact, the project proposes 0.04 acres of hand clearing associated with
the onsite detour.
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. 3b. 3c. 3d. 3e. 3f. 39 �
Stream impact Type of impact Stream name Perennial Type of jurisdiction Average Impact
number - (PER) or (Corps - 404, 10 stream length
Permanent (P) or intermittent DWQ - non-404, width (linear
Temporary (T) (INT)? other) (feet) feet)
Stream bank � PER � Corps
S1 � P O T stabilization Cane Creek � �NT � DWQ 30-40 75
S2 ❑ P� T Temporary Cane Creek � PER � Corps 30-40 20
construction ❑ INT ❑ DWQ
3h. Total Permanent Stream and Tributary Impacts 95
3i. Comments: Of the 95 LF of stream impacts, only 75 LF are associated with permanent impacts to the stream resulting
from the stream bank stabilization necessary after the removal of the old bridge abutments. The impacts do not extend into
the thalweg of the channel.
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 type Area of impact (acres)
Permanent(P)
orTem ora T
01 ❑POT
4f. Total open water impacts
4g. Comments: No open water impacts
5. Pond or Lake Construction
If ond or lake construction ro osed, then com lete the chart below.
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PCN Form - Version 1.3 December 10, 2008 Version

5a. 5b. 5c. 5d. 5e.
Wetland Impacts (acres) Stream Impacts (feet) Upland
Pond ID Proposed use or purpose of (acres)
number pond
Flooded Filled Excavated Flooded Filled Excavated Flooded
P1
P2
5f. Total
5g. Comments: There are no ponds created for this project
5h. Is a dam high hazard permit required?
❑ Yes ❑ No If yes, permit ID no:
5i. Expected pond surtace 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 aIl buffer impacts
below. If an im acts re uire miti ation, then ou MUST fill out Section D of this form.
6a.
❑ Neuse ❑ Tar-Pamlico ❑ Other: Jordan Lake
Project is in which protected basin? ❑ Catawba ❑ Randleman
6b. 6c. 6d. 6e. 6f. 6g.
Buffer impact
number— Reason Buffer Zone 1 impact Zone 2 impact
Permanent (P) for Stream name mitigation (square feet) (square feet)
or Tem ora T irn act re uired?
61 ❑ P❑ T Bridge ❑ Yes
Crossing ❑ No
6h. Total buffer impacts
6i. Comments:
D. ImpactJustification and Mitigation
7. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
The proposed project is to remove and replace a structurally deficient bridge and replace it with a new, longer bridge.
Roadway approach work is minimized as much as is practical to reduce the overall project footprint. An on-site detour will be
necessary as the only detour route would take travelers north into Virginia which was not viable. Bank stabilization will be
minimized to those areas where deemed necessary.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Erosion and sedimentation control BMPs will be installed prior to the start of construction of the project. The stream will be
temporarily diverted through a pipe (in place) during construction to minimize downstream impacts and to insure that aIl work
is conducted "in the dry." Impacts will be minimized by strict enforcement of Best Management Practices for the protection of
surFace waters, restrictions against the staging of equipment in or adjacent to waters of the US and coordination (including a
pre-construction meeting) with the Division Environmental Supervisor.
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PCN Form — Version 1.3 December 10, 2008 Version

2, Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State?
*We do not believe that mitigation should be required for
the permanent fills associated with this project as they are
Iimited to the stream bank location(s) where the old bridge
abutments were previously located. There is no proposal
to impact the thalweg of the channel. Further, NCDOT is ❑ Yes � No
improving the conditions of the stream channel at this site
by increasing the hydraulic opening with the new, longer
bridge. The pattern, dimension and profile of the stream
channel will not be permanently changed and/or damaged
with the inclusion of the rip rap at the proposed stream
bank location.
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. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter) Type Quantity
3c. Comments:
4. Complete if Making a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached. ❑ Yes
4b. Stream mitigation requested:
4c. If using stream mitigation, stream temperature: ❑ warm ❑ cool ❑cold
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.
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PCN Form—Version 1.3 December 10, 2008 Version

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 ❑ 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 restoration, payment into an approved in-lieu fee fund).
6h. Comments:
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PCN Form — Version 1.3 December 10, 2008 Version

2. Stormwater Mana ement Pian
2a. What is the overall percent imperviousness of this project? N/A %
2b. Does this project require a Stormwater Management Plan? � Yes ❑ No
2c. If this project DOES NOT require a Stormwater Management Plan, expiain why:
2d. If this project DQES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
There will be no deck drains on the new bridge. Storm water will conveyed to the existing ditches. See attached plan.
❑ Certified Local Government
2e. Who will be responsible for the review of the Stormwater Management Plan? ❑ DWQ Stormwater Program
� DWQ 401 Unit
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project?
❑ 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 ram-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
attached? ❑ Yes ❑ No
5. DWQ 401 Unit Stormwater 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
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PCN Form — Version 1.3 December 10, 2008 Version

F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1a. Does the project involve an expenditure of public (federal/state/local) funds or the � Yes ❑ No
use of public (federaUstate) Iand?
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 � No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
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:
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 Surtace Water or Wetland Standards, ❑ Yes � No
or Riparian Buffer Rules (15A NCAC 26 .0200)?
2b. Is this an after-the-fact permit application? ❑ Yes � 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 � 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.
Per the NC DWQ April 10, 2004 Version 2.1 Cumulative Impacts policy, small scale public transportation projects — such
as widening projects, bridge replacements and intersection improvements — have a"low potential for cumulative impact
since little (if any) new impervious surtace is added and the projects are usually in already developed locales." This
proposed project is within a somewhat developed landscape (i.e. existing residential homes in the vicinity), this is not a
road on a new location (i.e. there is an existing road and bridge structure and thus, the area already contains impervious
surfaces) and the project drains to Beaver Creek which is Class WS-IV (i.e. not HWQ or ORW or 303(d) listed waters).
We anticipate the NC DWR will advise us if a qualitative or quantitative analysis is needed.
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.
It is not anticipated that this project will generate any wastewater as it is a roadway project.
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PCN Form — Version 1.3 December 10, 2008 Version

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or � Yes � No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act � yes ❑ No
impacts?
� Raleigh
5c. If yes, indicate the USFWS Field Office you have contacted.
❑ Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
Piease see the attached emaii from Mr. Gary Jordan concurring with the "No EffecY' biological conclusion with respect to
the James spinymussel. Further, with the recent listing of the Northern Long Eared Bat (NLEB) in all Counties of NC, Mr.
Gary Jordan (USFWS) provided Divisions 1-8 a signed Programmatic Conference Opinion (PCO) for the NLEB (which
will need to be converted into a biological opinion). This will provide "incidental take" for all NCDOT projects with a
federal nexus in Divisions 1-8 for the next 5 years. As listed in the conclusion of the PCO, `After reviewing the cur�ent
status of the NLEB, fhe environmenfal baseline of the action area, the effects of the proposed action and cumulative
effecfs, rt is the Service's conference opinion that NCDOT acfivifies in easfern North Carolina (Divisions 1-8), as
proposed, are not likely to jeopardize the continued existence of fhe NLEB. No criiical habitaf has been proposed or
designated for the NLEB; therefore, none will be affecied."
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? ❑ Yes � No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
This bridge replacement project takes place in Alamance County which is not near any coastal or tidal habitat that would
support EFH (i.e. salt marshes, oyster reefs, etc.).
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 � 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?
See attached letters.
8. Plood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain? ❑ Yes � No
8b. If yes, explain how project meets FEMA requirements:
Sc. What source(s) did you use to make the floodplain determination? North Carolina Floodplain Mapping Program
Mr. Mike Mills, PE `
ApplicanUAgenYs Printed Name �i /T
pplicanUAgenYs Signature D e
(Agenfs signature is valid only if an authorization letter from the
a licant is rovided.
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PCN Form — Version 1.3 December 10, 2008 Version