20230788 Ver 1_ePCN Application_20230602

i DWR
Division of Water Resources
Pre -Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
April 13, 2022 Ver 4.3
Initial Review
Has this project met the requirements for acceptance in to the review process?
Yes
No
Is this project a public transportation project?*
Yes No
Change only If needed.
Pre -Filing Meeting Date Request was submitted on:
4/5/2023
BIMS # Assigned
20230788
Is a payment required for this project?*
No payment required
Fee received
Fee needed - send electronic notification
Reviewing Office*
Winston-Salem Regional Office - (336) 776-
9800
Information for Initial Review
la. Name of project:
Greendale Way Culvert Replacement
la. Who is the Primary Contact?*
Mike Gunnell, Village Manager
1b. Primary Contact Email:
[e-mail]
Date Submitted
6/2/2023
Nearest Body of Water
Muddy Creek
Basin
Yadkin-PeeDee
Water Classification
C
Site Coordinates
Latitude:
36.03685
A. Processing Information
Is this project connected with ARPA funding?
Yes No
County (or Counties) where the project is located:
Forsyth
Is this a NCDMS Project
Yes No
Longitude:
-80.37215
Version#*
1
What amout is owed?*
$240.00
$570.00
Select Project Reviewer*
Seren Homer:[e-mail]
1c. Primary Contact Phone:*
[phone]
O

Is this project a public transportation project?*
Yes No
1a.Type(s)of approval sought from the Corps:
Section 404 Permit (wetlands, streams and waters, Clean Water Act)
Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
Has this PCN previously been submitted?*
Yes
No
1b. What type(s) of permit(s) do you wish to seek authorization?
Nationwide Permit (NWP)
Regional General Permit (RGP)
Standard (IP)
1c. Has the NWP or GP number been verified by the Corps?
Yes No
Nationwide Permit (NWP) Number: 03 - Maintenance
NWP Numbers (for multiple NWPS):
1d. Type(s) of approval sought from the DWR:
401 Water Quality Certification - Regular
Non-404 Jurisdictional General Permit
Individual 401 Water Quality Certification
401 Water Quality Certification - Express
Riparian Buffer Authorization
le. Is this notification solely for the record because written approval is not required?
For the record only for DWR 401 Certification: Yes No
For the record only for Corps Permit: Yes No
1f. Is this an after -the -fact permit application? *
Yes No
1g. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
Yes No
1g. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
Yes No
1h. Is the project located in any of NC's twenty coastal counties?
Yes No
1j. Is the project located in a designated trout watershed?
Yes No
B. Applicant Information
1d. Who is applying for the permit?
Owner Applicant (other than owner)
le. Is there an Agent/Consultant for this project?
Yes No
2. Owner Information
2a. Name(s) on recorded deed:
Village of Clemmons
2b. Deed book and page no.:
NA
2c. Contact Person:
Mike Gunnell, Village Manager

2d. Address
Street Address
3715 Clemmons Road
Address Line 2
city
Clemmons
Postal / Zip Code
27012
2e. Telephone Number:
[phone]
2g. Email Address:*
[e-mail]
4. Agent/Consultant (if applicable)
4a. Name:
Amy Black, Project Manager
4b. Business Name:
LJB Engineering PC
4c.Address
Street Address
311-A South Main Street
Address Line 2
city
Kernersville
Postal / Zip Code
27284
4d. Telephone Number:
[phone]
4f. Email Address:*
[e-mail]
C. Project Information and Prior Project History
1. Project Information
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality / town:
Village of Clemmons
2. Project Identification
2a. Property Identification Number:
5893-44-2904
2c. Project Address
Street Address
4630 Greendale Way
Address Line 2
city
Clemmons
Postal / Zip Code
27103
3. Surface Waters
3a. Name of the nearest body of water to proposed project:
Muddy Creek
3b. Water Resources Classification of nearest receiving water:
C
3c. What river basins) is your project located it *
Yadkin-PeeDee
State / Province / Region
NC
Country
us
2f. Fax Number:
State / Province / Region
NC
Country
us
4e. Fax Number:
2b. Property size:
1.19
State / Province / Region
NC
Country
us

3d. Please provide the 12-digit HUC in which the project is located.
030401011306
4. Project Description and History
4a. 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 Village of Clemmons is proposing improvements to the culvert at Greendale Way. The project limits are located on Greendale Way roughly 530 feet from Brookland Drive. Land use in
the project area is residential and includes a small neighborhood park. The existing culvert is undersized and in large storm events, flooding occurs at the adjacent home.
4b. Have Corps permits or DWR certifications been obtained for this project (including all prior phases) in the past?
Yes No Unknown
4f. List the total estimated acreage of all existing wetlands on the property:
0
4g. List the total estimated linear feet of all existing streams on the property:
500
4h. Explain the purpose of the proposed project:*
This project will replace an undersized culvert with a twin concrete box culvert to reduce flood risk in this area.
4i. Describe the overall project in detail, including indirect impacts and the type of equipment to be used: *
The proposed culvert will include TxT and Tx6' boxes, with the larger set at the stream invert elevation. Due to an existing sanitary sewer, there is not sufficient vertical space to bury the
culvert to provide a foot of soil for a natural bottom. We are proposing to provide a notch in the lower culvert to allow concentrated flow for aquatic passage during low flow. Concrete
wingwalls will be constructed at the upstream and downstream ends of the culvert. Riprap will be installed at both upstream and downstream ends to provide erosion protection and energy
dissipation. The existing culvert is 64 LF. The proposed culvert is 48 LF with approximately 10 LF of riprap and wingwall on each end for a total stream impact of 68 LF. The LOD and
temporary construction easements extend beyond the infrastructure to allow for grading to accommodate the larger culvert, for a total length of stream impact of 90 LF - 68 permanent and
22 temporary.
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or proposed impact areas?*
Yes No O Unknown
Comments:
Project limits are limited to culvert crossing only
5b. If the Corps made a jurisdictional determination, what type of determination was made?
Preliminary Approved Not Verified Unknown N/A
Corps AID Number:
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Other:
6. Future Project Plans
6a. Is this a phased project?*
Yes No
Are any other NWP(s), regional general permit(s), or individual permits(s) used, or intended to be used, to authorize any part of the proposed project or related activity?
NA
D. Proposed Impacts Inventory
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
Wetlands Streams -tributaries Buffers
Open Waters Pond Construction
3. Stream Impacts
L
F
S1
3a. Reason for impact (?)
Culvert replacement
3b.lmpact type*
Permanent
3c. Type of impact*
Culvert
3d. S. name*
Unnamed Trib
3e. Stream Type*
?)
Perennial
f. Type of
*
[Juriscliction
Both
3g. S. width
12
Average (feet)
3h. Impact
length*
68
(linear feet)
g2
Culvert replacement
Temporary
Culvert
Unnamed Trib
Perennial
Both
12
Aveage (feet)
22
(linear feet)

3i. Total jurisdictional ditch impact in square feet:
0
3i. Total permanent stream impacts: 3i. Total temporary stream impacts:
68 22
3i. Total stream and ditch impacts:
90
3j. Comments:
Permanent impacts are limited to the proposed culvert, headwall, and riprap at upstream and downstream aprons. Minimal grading is proposed to
accommodate the expanded box culverts.
E. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:
Proposed riprap will provide energy dissipation to reduce sedimentation and improve water quality downstream. The project footprint has been
minimized to the extent possible.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:
Erosion and sediment control practices for this project will include pump around to allow all stream work to be completed in dry conditions. Appropriate
soil erosion and sediment controls will be used and maintained in effective operating condition during construction, and all exposed soil and other fills, as
well as any work below the ordinary high-water mark, will be permanently stabilized at the earliest
practicable date.
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 this project DOES NOT require Compensatory Mitigation, explain why:
The proposed project is designed to avoid adverse effects to waters of the U.S. and will not impacts wetlands.
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
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
If no, explain why:
The project is located within the Yadkin -Pee Dee River Basin. No impervious area is being added as part of this project.
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?
Yes No
2b. Does this project meet the requirements for low density projects as defined in 15A NCAC 02H .1003(2)?
Yes No
Comments:
No impervious area is being added as part of this project.
G. Supplementary Information
1. Environmental Documentation
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
Comments: *
Project only involves environmental enhancement and replacement of existing structure. There will be no additional impervious area.
2. Violations (DWR Requirement)
O
O
2a. Is the site in violation of DWR Water Quality Certification Rules (15A NCAC 2H .0500), Isolated Wetland Rules (15A NCAC 2H .1300), or DWR Surface Water or Wetland Standards or
Riparian Buffer Rules (15A NCAC 2B .0200)? *
Yes No

3. Cumulative Impacts (DWR Requirement)
3a. Will this project result in additional development, which could impact nearby downstream water quality?
Yes No
3b. If you answered "no," provide a short narrative description.
This project replaces an existing culvert.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?
Yes No N/A
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
5d. Is another Federal agency involved?*
Yes No
5e. Is this a DOT project located within Division's 1-8?
Yes No
5f. Will you cut any trees in order to conduct the work in waters of the U.S.?
Yes No
5g. Does this project involve bridge maintenance or removal?
Yes No
5h. Does this project involve the construction/installation of a wind turbine(s)?*
Yes No
Unknown
5L Does this project involve (1) blasting, and/or (2) other percussive activities that will be conducted by machines, such as jackhammers, mechanized pile drivers, etc.?
Yes No
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
IPaC Resource List for proposed project area reported no critical habitat in our project area:
https://ipac. ecosphe re.fws.gov/projecVGJ O P55ZQ D5B MTN HYKS D V H F D5TQ/resources
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?
Yes No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?
IPaC Resource List for proposed project area: https://ipac.ecosphere.fws.gov/project/GJOP55ZQD5BMTNHYKSDVHFD5TQ/resources
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?
Yes No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources? *
The project does not propose to rehabilitate, alter, remove, or demolish any historic property within the project area and does not involve any land
acquisition or impacts to historic architecture or adverse impacts to adjacent right-of-way. No impacts to historic structures or properties are anticipated
as a result of the culvert replacement project. The Hope -Fraternity Historic District (FY3916) is located approximately 1.75 miles to the southeast. A
formal Project Review by SHPO was not requested following review of http://gis.ncdcr.gov/hpoweb/ data source.
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain?
Yes No
8c. What source(s) did you use to make the floodplain determination?
https://msc.fema.gov/portal/search
http://fris.nc.gov/fris/index.aspx?FIPS=001&ST=NC&user=General Public
Miscellaneous
8

Please use the space below to attach all required documentation or any additional information you feel is helpful for application review. Documents should be combined into one file when
possible, with a Cover Letter, Table of Contents, and a Cover Sheet for each Section preferred.
Click the upload button or drag and drop files here to attach document
Greendale Way Culvert Replacement—PCN documents.pdf 6.74MB
File must be PDF or KMZ
Comments
Signature
By checking the box and signing below, I certify that:
• The project proponent hereby certifies that all information contained herein is true, accurate, and complete to the best of my knowledge and belief'; and
• The project proponent hereby requests that the certifying authority review and take action on this CWA 401 certification request within the applicable reasonable period of time.
• 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:
Amy Black
Signature
Date
6/2/2023
M