20230901 Ver 1_ePCN Application_20230621

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:
6/15/2023
BIMS # Assigned
20230901
Is a payment required for this project?*
No payment required
Fee received
Fee needed - send electronic notification
Select Project Reviewer*
Seren Homer:[e-mail]
Information for Initial Review
la. Name of project:
COURTESY COPY 1-74 Industrial Center Sewer Improvements
1a. Who is the Primary Contact?*
Paxton Arthurs
1b. Primary Contact Email: *
[e-mail]
Date Submitted
6/21 /2023
Nearest Body of Water
Deep River
Basin
Cape Fear
Water Classification
Deep River
Site Coordinates
Latitude:
35.829037
A. Processing Information
Longitude:
-79.839264
Is this project connected with ARPA funding?
Yes No
Please provide the DWI ARPA Funding Project Number (ie: SRP-W-ARP-0321)
Direct appropriation to Randolph Co.
County (or Counties) where the project is located:
Randolph
Version#*
1
Reviewing Office *
Winston-Salem Regional Office - (336) 776-
9800
1c. Primary Contact Phone: *
[phone]
Is this a NCDMS Project
Yes No

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: 12 - Utility Lines
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:
Randolph County
2b. Deed book and page no.:
002843/01312
2c. Contact Person:
Paxton Arthurs

2d. Address
Street Address
1413-1401 Commonwealth Rd
Address Line 2
City
Spohia
Postal / Zip Code
27205
2e. Telephone Number:
[phone]
2g. Email Address:*
[e-mail]
2a. Narri on recorded deed:
Gracie Hatcher
2b. Deed book and page no.:
001073/00578
2c. Contact Person:
2d.Address
Street Address
410 Brookshire Rd
Address Line 2
City
Randleman
Postal / Zip Code
27317
2e. Telephone Number:
[phone]
2g. Email Address:*
[e-mail]
3. Applicant Information (if different from owner)
3a. Name:
Randolph County
3b. Business Name:
3c. Address
Street Address
725 McDowell Road
Address Line 2
City
Asheboro
Postal / Zip Code
2
3d. Telephone Number:
[phone]
3f. Email Address:*
[e-mail]
4. Agent/Consultant (if applicable)
4a. Name:
John Grey
4b. Business Name:
The Wooten Company
State / Province / Region
NC
Country
USA
2f. Fax Number:
State / Province / Region
NC
Country
US
2f. Fax Number:
State / Province / Region
NC
Country
USA
3e. Fax Number:

4c.Address
Street Address
300 South Main Street
Address Line 2
city
Winston-Salem
Postal / Zip Code
27101
4d. Telephone Number:
[phone]
4f. Email Address:*
[e-mail]
C. Project Information and Prior Project History
1. Proiect Information
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality I town:
Randleman
2. Project Identification
2a. Property Identification Number:
7755172540
2c. Project Address
Street Address
1413-1401 Commonwealth Rd
Address Line 2
City
Sophia
Postal / Zip Code
27350
3. Surface Waters
3a. Name of the nearest body of water to proposed project:
Deep River
3b. Water Resources Classification of nearest receiving water:"
Deep River
3c. What river basin(s) is your project located in?*
Cape Fear
3d. Please provide the 12-digit HUC in which the project is located.
0303000302
4. Project Description and History
State / Province / Region
NC
Country
USA
4e. Fax Number:
2b. Property size:
0.7
State / Province / Region
NC
Country
USA
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: "
Road shoulders and streets. Forest lands and farmlands near the Gravity Sewer.
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:
110
4h. Explain the purpose of the proposed project: *
Project involves the instillation of approximately 5,064 LF of 12-inch diameter gravity sewer lines, a 730 gpm sewer pump station, and approximately 12,546 LF of 12-inch diameter force
main.
4i. Describe the overall project in detail, including indirect impacts and the type of equipment to be used: *
Project involves the instillation of approximately 5,064 LF of 12-inch diameter gravity sewer lines, a 730 gpm sewer pump station, and approximately 12,546 LF of 12-inch diameter force
main. The equipment to be used is anticipated to be one or two back hoes and a loader.
5. Jurisdictional Determinations

5a. Have the wetlands or streams been delineated on the property or proposed impact areas?
Yes No Unknown
Comments:
All Streams have been identified using GIS data.
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?
Not to our knowledge.
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
`W
F
S1
3a. Reason for impact (?)
Gravity Sewer Line
3b.lmpact type*
Temporary
3c. Type of impact*
Excavation
3d. S. name*
unnamed
3e. Stream Type*
?)
Intermittent
3f. Type of
Jurisdiction*
Both
3g. S. width
Average (feet)
3h. Impact
length*
40
(linear feet)
Sp
Sewer Force Main InttItt:]
Excavation
unnamed
Intermittent
Both
Averege(feeq
30
(iinearfeet)
31. Total jurisdictional ditch impact in square feet:
0
3i. Total permanent stream impacts: 3i. Total temporary stream impacts:
0 70
31. Total stream and ditch impacts:
70
3j. Comments
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:
Restricted work area for contractor. Used HDD on some creek crossings.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:
Erosion and sedimentation control devices installed including temporary creek crossings.
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
0
V

2b. If this project DOES NOT require Compensatory Mitigation, explain why:
Total footage of streams impacted is less than NWP limits.
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
1. Diffuse Flow Plan
la. Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian Buffer Protection Rules?
Yes No
What type of SCM are you providing?
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
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:
G. Supplementary Information
1. Environmental Documentation
la. 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:
N/A
2. Violations (DWR Requirement)
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
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
5c. If yes, indicate the USFWS Field Office you have contacted.
Raleigh
5d. Is another Federal agency involved?*
Yes No
Unknown

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
5i. 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?
https:/Iwww.nconemap.gov/maps/NC::biodiversity-and-wildlife-habitat-assessment/explore?location=35.825755 % 2C-79.819752 / 2C15.77
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?
USFWS website
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?
https://nc.maps.arcgis.com/home/group.htmi?
id=d56ec9c8aa77423b931f4d359f1 03ae6% 2Fhpoweb % 2Fdefault.htm&view=list&categories= % 5B % 22 % 2FCategories % 2FHPOWEB % 22 % 5D#contenU
hpoweb/
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://fris.nc.gov/fris/Index.aspx?user=General % 20Public&address=Randleman&ST=NC&ST=NC#
Miscellaneous
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
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:
John Grey
Signature
0&-C'L-;Ft�
Date
6/21 /2023