20150571 Ver 1_Application_20150610

Pre-Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1a. Type(s) of approval sought from the
Corps: Section 404 Permit Section 10 Permit
1b. Specify Nationwide Permit (NWP) number: 14 or General Permit (GP) number:
1c. 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
1e. Is this notification solely for the record
because written approval is not required?

For the record only for DWQ 401
Certification:
Yes No
For the record only for Corps Permit:

Yes 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 or in-lieu
fee program.
Yes No

1g. Is the project located in any of NC’s twenty coastal counties. If yes, answer 1h
below.
Yes No

1h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? Yes No
2. Project Information
2a. Name of project: Hwy 401 safety upgrade
2b. County: Hoke
2c. Nearest municipality / town: Rock Fish
2d. Subdivision name: N/A
2e. NCDOT only, T.I.P. or state
project no: W-5208J
3. Owner Information
3a. Name on Recorded Deed: NC DOT
3b. Deed Book and Page No. NA
3c. Responsible Party (for LLC if
applicable):
3d. Street address: PO BOX 1067
3e. City, state, zip: Aberdeen, NC 28315
3f. Telephone no.: 910-944-2344
3g. Fax no.: 910-944-5623
3h. Email address: @ncdot.gov
Office Use Only:
Corps action ID no. _____________
DW Q project no. _______________
Form Version 1.0 November 2008
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PCN Form – Version 1.0 November 2008 Version

Section A. Applicant Information, continued

4. Applicant Information (if different from owner)
4a. Applicant is: Agent Other, specify: Division Environmental Officer
4b. Name: Art King
4c. Business name
(if applicable): North Carolina Department of Transportation
4d. Street address: PO BOX 1067

4e. City, state, zip: Aberdeen, NC, 28315
4f. Telephone no.: 910-944-2344
4g. Fax no.: 910-944-5623
4h. Email address: [e-mail]
5. Agent/Consultant Information (if applicable)
5a. Name:
5b. Business name
(if applicable): North Carolina Department of Transportation
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:

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PCN Form – November 2008 Version

B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID): DB 971 PG 973
1b. Site coordinates (in decimal degrees): 35.03231‘N - 79.089086‘W
1c. Property size: 1 acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
proposed project: UT of Stewarts Creek
2b. Water Quality Classification of nearest receiving water: C
2c. River basin: Cape Fear
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:
Commercial/Church property
3b. List the total estimated acreage of all existing wetlands on the property:
Approx. 1 ac
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
0
3d. Explain the purpose of the proposed project:
To install an upgraded turn lane and turn about extension (bump out) between the Raeford Christian Fellowship Church
entrance and a neighboring housing development entrance, to improve safety along Hwy 401 for cars making a U- turn to
reach the church. Also to reduce traffic of larger truck attempting to make a left turn onto Wayside Drive from Hwy 401
east
3e. Describe the overall project in detail, including the type of equipment to be used:
To clear,grade, base the area for the bump out and build a fill section large to accommodate the bump out. Equip used:
dump trucks, track hoe, dozer, compactor, paving equipment.
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past?
Yes No Unknown
4b. If the Corps made the jurisdictional determination, what type
of determination was made? Preliminary Final
4c. If yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
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
this project (including all prior phases) in the past? Yes No Unknown
5b. If yes, explain in detail according to “help file” instructions.

6. Future Project Plans
6a. Is this a phased project? Yes No
6b. If yes, explain.

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PCN Form – Version 1.0 November 2008 Version

C. Proposed Impacts Inventory
1. Impacts Summary
1a. 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.
Wetland impact
number –
Permanent (P) or
Temporary (T)
2b.

Type of
impact
2c.

Type of wetland
(if known)
2d.

Forested

2e.
Type of jurisdiction
(Corps - 404,
DWQ – non-404, other)
2f.

Area of impact (acres)
W1 P T Road Fill Yes No Corps
DWQ 0.10 ac
W2 P T Yes No Corps
DWQ
W3 P T Yes No Corps
DWQ
W4 P T Yes No Corps
DWQ
W5 P T Yes No Corps
DWQ
W6 P T Yes No Corps
DWQ
2g. Total wetland impacts 0.10 ac
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.
Stream impact
number -
Permanent (P) or
Temporary (T)
3b.
Type of
impact
3c.
Stream name
3d.
Perennial (PER) or
intermittent (INT)?
3e.
Average stream width (feet)
3f.
Impact
length
(linear feet)

S1 P T PER INT
S2 P T PER INT
S3 P T . PER INT
S4 P T PER INT
S5 P T PER INT
S6 P T PER INT
3g. Total stream and tributary impacts
3h. Comments:
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PCN Form – Version 1.0 November 2008 Version

C. Proposed Impacts Inventory, continued

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.
Open water
impact number
– Permanent
(P) or
Temporary (T)
4b.
Name of
waterbody
(if
applicable)
4c.

Type of impact
4d.

Waterbody type
4e.

Area of impact (acres)
O1 P T NA
O2 P T
O3 P T
O4 P T
4f. Total open water impacts 0
4g. Comments:
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PCN Form – November 2008 Version

C. Proposed Impacts Inventory, continued

5. Pond or Lake Construction
If pond or lake construction proposed, then complete the chart below.
5a.

Pond ID
number
5b.

Proposed use or
purpose of pond

5c.
Wetland Impacts (acres)
5d.
Stream Impacts (feet)
5e.
Upland
(acres)
Flooded Filled Excavated Flooded Filled Excavated Flooded
P1 NA
P2
5f. Total
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.
6a.
Project is in which protected basin?
Neuse Tar-Pamlico Other:
Catawba Randleman
6b.
Buffer impact
number –
Permanent (P)
or Temporary
(T)
6c.

Reason
for impact
6d.

Stream name
6e.

Buffer
mitigation
required?

6f.

Zone 1 impact (square
feet)
6g.

Zone 2 impact
(square feet)
B1 P T NA Yes No
B2 P T Yes No
B3 P T Yes No
6h. Total buffer impacts
6i. Comments: Not in a buffer area.
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PCN Form – November 2008 Version

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
Only the minimum amount of fill materal installed to provide a safe structure and meet current standards.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Install erosion control devices and compliance with all current BMP.
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?
Yes No

2b. If yes, mitigation is required by (check all that apply): DWQ Corps
2c. If yes, which mitigation option will be used for this
project?
Mitigation bank
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: linear feet
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 1.0 November 2008 Version

D. Impact Justification and Mitigation, continued

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
buffer mitigation?
Yes No

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.
Zone Reason for impact Total impact
(square feet) Multiplier Required mitigation
(square feet)
Zone 1 NA 3 (2 for Catawba)
Zone 2 1.5
Total buffer mitigation required:
6c. 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).

6d. Comments:

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PCN Form – November 2008 Version

E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1a. Does the project include or is it adjacent to protected riparian buffers identified
within one of the NC Riparian Buffer Protection Rules? Yes No
1b. If yes, then is a diffuse flow plan included? Yes No
2. Determination if the Project Requires a Stormwater Management Plan
2a. Does the project require a Non-404 Jurisdictional General Permit? Yes No
2b. Is the project subject to General Certification 3704 or 3705? Yes No
3. Determination of Stormwater Review Jurisdiction
3a. Is this project subject to any of the following state-implemented stormwater
management programs (check all that apply)?
If so, attach one copy of the approval letter from the DWQ and one copy of the
approved stormwater management plan.
Coastal counties
HQW
ORW
Session Law 2006-246
Other:
3b. In which local government’s jurisdiction is this project? Hoke County
3c. Is this local government certified to implement a state stormwater program?
If so, attach one copy of the approval letter from the local government and one copy
of the approved stormwater management plan (or one copy of the approved
Stormwater management plan stamped as approved).
Yes No
4. Information Required for DWQ 401 Unit Stormwater Review
4a. What is the overall percent imperviousness according to the most current site plan? <24%
4b. Does this project contain any areas that meet the criteria for “high density” per
General Certifications 3704 and 3705? Yes No
4c. If the site is over 24% impervious and/or contains high density areas, then provide a brief narrative description of the
stormwater management plan.

4d. Has a completed BMP Supplement Form with all required items been submitted
for each stormwater BMP? Yes No

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PCN Form – Version 1.0 November 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
use of public (federal/state) land? Yes No
1b. If you answered “yes” to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
Yes No
1c. If you answered “yes” to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
letter.)
Comments:
Yes No
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,
or Riparian Buffer Rules (15A NCAC 2B .0200)?
Yes No
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): Due to a
miscommunication, our directions to limit the clearing on the site to " hand clearing only, and no grubbing past the existing
toe of slope", was misintrepreted by the contractor to mean "to the toe of the newly proposed slope". This led to the
contractor clearing and grubbing within the suspected wetland area prior to receipt of the permit.
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in
additional development, which could impact nearby downstream water quality? Yes No
3b. If you answered “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.
NA
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PCN Form – Version 1.0 November 2008 Version
F. Supplementary Information, continued

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
habitat? Yes No
5b. Have you checked with the USFWS concerning Endangered Species Act
impacts? Yes No
5c. If yes, indicate the USFWS Field Office you have contacted. Raleigh
Asheville
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
On site survey by NCDOT staff,and NCDOT SDV reference layer.
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?

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
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
Yes No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?

8. Flood 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:
8c. What source(s) did you use to make the floodplain determination? FEMA mapping

Applicant/Agent's Printed Name

_______________________________
Applicant/Agent's Signature
(Agent's signature is valid only if an authorization letter from the applicant
is provided.)

Date

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PCN Form – November 2008 Version