20150793 Ver 1_Application_20150806

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Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Pre-Construction Noti�cation PC Form
A. A licant Information
1. Processing
1 a. Type(s) of approval sought from the
Corps: � Section 404 Permit ❑ Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: 3 or General Permit (GP) number:
1 c. Has the NWP or GP number been verified by the Corps? ❑ Yes � No
1 d. 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 letter 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 Richmond Bridge #93
2b. County: Richmond
2c. Nearest municipality / town: Ellerbe
2d. Subdivision name:
2e. NCDOT only, T.I.P. or state 176P.8.R.58
project no:
3. Owner Information
3a. Name(s) on Recorded Deed: NA
3b. Deed Book and Page No.
3c. Responsible Party (for LLC if
applicable):
3d. Street address:
3e. City, state, zip:
3f. Telephone no.:
3g. Fax no.:
3h. Email address:
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PCN Form — Version 1.3 December 10, 2008 Version

4. Applicant Information (if different from owner)
4a. Applicant is: � Agent ❑ Other, specify:
4b. Name: Art King
4c. Business name NCDOT Hi hwa Div. 8
(if annlicahlal� 9 y
4d. Street address: 902 North Sandhill Blvd.
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. AgenUConsultant Information (if applicable)
5a. Name:
5b. Business name
Sc. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fax no.:
5g. Email address:
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PCN Form — Version 1.3 December 10, 2008 Version

B. Project Information and Prior Project History
7. Property Identification
1 a. Property identification no. (tax PIN or parcel ID):
1b. Site coordinates (in decimal degrees):
1c. Propertysize:
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to
2b. Water Quality Classification of nearest receiving water:
2c. River basin:
Latitude: 35.11472
(DD.DDDDDD)
1 acres
Dry Creek
C
Yadkin-PeeDee
Longitude: - 80.00519
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:
Rural agricultural/ timber
3b. List the total estimated acreage of all existing wetlands on the property:
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
100ft
3d. Explain the purpose of the proposed project:
To replace a an older timber bridge with a modern structure that meets current safety standards.
3e. Describe the overall project in detail, including the type of equipment to be used:
Replace the current bridge using: Crane , trackhoe, dump trucks, paver, compactor dozer.
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
Comments:
4b. If the Corps made the jurisdictional determination, what type
of determination was made? ❑ Preliminary � Final
❑ Unknown
4c. If yes, who delineated the jurisdictional areas? Agency/Consultant Company:
Name (if known): A. Efrid, D. O'loughlin 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 � Yes
this project (including all prior phases) in the past?
5b. If yes, explain in detail according to "help file" instructions.
6. Future Proiect Plans
6a. Is this a phased project?
6b. If yes, explain.
❑ Yes
1� .
►1 .
❑ Unknown
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PCN Form — Version 1.3 December 10, 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. 2b. 2c. 2d. 2e. 2f.
Wetland impact T
number — T e of im act T e of wetland Forested yPe of jurisdiction
Yp p Yp (Corps - 404, 10 Area of impact
Permanent (P) or (if known) DWQ — non-404, other) (acres)
Tem ora T
W1 � P❑ T fill riverine � Yes � Corps
� No ❑ DWQ 0.01
W2 � P� T ❑ Yes ❑ Corps
❑ No ❑ DWQ
W3 ❑ P❑ T ❑ Yes ❑ Corps
❑ No ❑ DWQ
W4 ❑ P❑ T ❑ Yes ❑ Corps
❑ No ❑ DWQ
W5 ❑ P � T ❑ Yes ❑ Corps
❑ No ❑ DWQ
W6 ❑ P❑ T ❑ Yes ❑ Corps
❑ No ❑ DWQ
2g. Total wetland impacts 0.01
2h. Comments: excavation and rip rap fill for armoring bridge
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. 3b. 3c. 3d. 3e. 3f. 3g.
Stream impact Type of impact Stream name Perennial Type ofjurisdiction Average Impact
number - (PER) or (Corps - 404, 10 stream length
Permanent (P) or intermittent
Tem ora T DWQ — non-404, width (linear
P �' ( ) (INT)? other) (feet) feet)
S1 � P❑ T fill Dry Creek � PER � Corps 20-25 50
❑ INT ❑ DWQ
S2 ❑ P� T fill �� � PER � Corps
❑ INT ❑ DWQ 20-25 60
S3 ❑ P❑ T ❑ PER ❑ Corps
❑ INT ❑ DWQ
S4 ❑ P❑ T ❑ PER ❑ Corps
❑ INT ❑ DWQ
SS ❑ P � T ❑ PER ❑ Corps
❑ INT ❑ DWQ
S6 ❑ P❑ T ❑ PER ❑ Corps
❑ INT ❑ DWQ
3h. Total stream and tributary impacts 110'
3i. Comments: total SW impact O.OSacres
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PCN Form — Version 1.3 December 10, 2008 Version

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) or
Tem ora T
01 ❑P❑T NA
02 ❑P❑T
03 ❑P❑T
04 ❑P�T
4£ Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If ond or lake construction ro osed, then com lete the chart below.
5a. 5b. 5c. 5d. 5e.
Wetland Impacts (acres) Stream Impacts (feet) Upland
Pond ID Proposed use or purpose (acres)
number of pond
Flooded Filled Excavated Flooded Filled Excavated Flooded
P1 NA
P2
Sf. Total
5g. Comments:
5h. Is a dam high hazard permit required?
❑ Yes ❑ No If yes, permit ID no:
Si. 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 an impacts require miti ation, then ou MUST fill out Section D of this form.
6a.
❑ Neuse ❑ Tar-Pamlico ❑ Other:
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) or for Stream name mitigation (square feet) (square feet)
Tem ora T im act re uired?
61 ❑P❑T NA ❑Yes
❑ No
B2 ❑P❑T ❑Yes
❑ Na
B3 ❑P❑T ❑Yes
❑ No
6h. Total buffer impacts
6i. Comments:
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PCN Form — Version 1.3 December 10, 2008 Version

D. Impact Justification and Mitigation
1. Avoidance and Minimization
� a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
minimum fill installed to establish a safe structure and roadway
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
All shaft and bent installation equipment will operate from the stream banks.
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?
2b. If yes, mitigation is required by (check all that appty):
2c. If yes, which mitigation option will be used for this
project?
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter)
3c. Comments:
4. Complete if Making a Payment to In-lieu Fee Program
❑ Yes � No
❑ DWQ ❑ Corps
❑ Mitigation bank
❑ Payment to in-lieu fee program
❑ Permittee Responsible Mitigation
Type I Quantity
4a. Approval letter from in-lieu fee program is attached. I❑ Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature:
4d. Buffer mitigation requested (DWQ only):
4e. Riparian wetland mitigation requested:
4f. Non-riparian wetland mitigation requested:
4g. Coastal (tidal) wetland mitigation requested:
4h. Comments:
❑ warm ❑ cool
square feet
acres
5. Complete if Using a Permittee Responsible Mitigation Plan
acres
acres
❑cold
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

E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers identified � Yes � No
within one of the NC Riparian Buffer Protection Rules?
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
Comments: ❑ Yes ❑ No
2. Stormwater Mana ement Plan
2a. What is the overall percent imperviousness of this project? 24 %
2b. Does this project require a Stormwater Management Plan? ❑ Yes � No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why: included in package but not required
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the 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 governmenYs 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)
1 a. Does the project involve an expenditure of public (federal/state/local) funds or the � Yes ❑ No
use of public (federal/state) land?
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)?
1 c. 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 Surface Water or Wetland Standards, ❑ Yes � No
or Riparian Buffer Rules (15A NCAC 2B .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.
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 su6ject facility.
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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
habitat? � No
5b. Have you checked with the USFWS concerning Endangered Species Act � Yes
impacts? � No
❑ Raleigh
Sc. 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?
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 � 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?
SHPO review
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?
,�,�T � �,�� C��C�� � s-,�-
Applicant/AgenYs Printed Name Applicant/AgenYs Signature Date
(AgenYs signature is valid only if an authoriZation letter from the applicant
is provided.
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PCN Form — Version 1.3 December 10, 2008 Version