20160805 Ver 1_Application_20160819

Carpenter,Kristi
From:Braquet, Stephanie
Sent:Friday, August 19, 2016 9:07 AM
To:[e-mail]; Wanucha, Dave
Cc:Crook, Mark; Carpenter,Kristi; Keen, Kiera T
Subject:Davidson County-Panther Lane
Attachments:permit application.pdf
Follow Up Flag:Follow up
Flag Status:Completed
Attached is the permit application for a pipe replacement project on Panther Lane in Davidson County.
If you have any questions or need further information, please feel free to contact me.

Stephanie Braquet

Division 9 Environmental Specialist

North Carolina Department of Transportation

336 747 7800 office

[e-mail]

375 Silas Creek Parkway

Winston Salem, NC 27127-7167

Email correspondence to and from this address is subject to the

North Carolina Public Records Law and may be disclosed to third parties.

Email correspondence to and from this sender is subject to the N.C. Public Records Law and may be disclosed to third parties.
1

Transportation
August 19, 2016
Mr. John Thomas
US Army Corps of Engineers
3331 Heritage Trade Dr.
Suite 105
Wake Forest, NC 27615
SUBJECT: Nationwide Permit #14
Replace pipe carrying Hamby Creek (Class C)
WBS Project No.: 9C.029110
Davidson County
Dear Mr. Thomas,
PAT McCRORY
Covemar
NICHOLAS J. TENNYSON
Secremry
We are requesting a Nationwide 14 permit for the pipe replacement on Panther Lane (SR 2848) over
Hamby Creek in Davidson County. I have attached a pre-construction notification application, a
topography map with the project area circled, a vicinity map, construction sequence, construction plans,
and Northern Long-eared bat (NLEB) Streamlined Consultation form. The project will permanently impact
10 linear feet and temporarily impact 8 linear feet (dewatering) of Hamby Creek.
The existing pipe is 30" x 50', reinforced concrete pipe (RCP). The new pipe will be a 36" x 60', corrugated
metal pipe (CMP). The site will be dewatered during construction in accorda�ce with NCDOT's Best
Management Practices. All disturbed areas will be re-vegetated and the project will be released by
NCDOT's Roadside Field Operations Engineer/Technician once 80% vegetative cover is achieved.
The USFWS lists Schweiniti s sunflower (Helionthus schweinitziiJ as endangered and the Northern Long-
eared bat (NLEB- Myotis septentrionolisJ as threatened in Davidson County. The Bald eagle (Halioeetus
leucocephalusJ is protected under the Bald and 6olden Eagle Protection Act (BGPA) in Davidson County.
There is no habitat for Schweinitz's sunflower or the Bald eagle in the project area; therefore, it was
determined that there will be `no effect' on these species. There is habitat for the NLEB, however, since
there are no known maternity roost trees within 150-foot radius of the project area and there are no
known hi6ernaculum within 0.25 miles of the project area, it was determined that the project may affect
but is not likely to adversely affect (MANLAA) the Northern Long-eared bat. See attached NLEB
Streamlined Consultation Form.
If you have any questions, comments or need additional information after reviewing this material please
contact me at [phone]. Thank you for your cooperation in this matter.
Environmental Spec/alrt, NCDOT Division 9
�Nothing Compares�.�..
Smte of North Carolina I Deparhnent of Transportation I Division 9- UNCC NAME
375SilasCreekParkway I Winstou-Salem,NC27727
[phone] T I [phone] F

Transportation
Attachments: Application Package and plans
CC:
PAT McCRORY
Govemor
M CHOLASJ.TENNYSON
Secretary
Mr. Dave Wanucha, NCDEQ-DWR, Environmental Specialist- e-copy
Mr. Pat Ivey, P.E., NCDOT- Division 9- Division Engineer- cover letter
Mr. Mark Gook, P.E., NCDOT-Division 9-Davidson County Maintenance Engineer
Mrs. Kiera Keen, NCDOT- Division 9 and 10, Roadside Environmental Technician
�Nothing Compares�.�_
StateofNo�thCaraliva � DepartmeutofTrensportanon I Divisio�9—UNPfNAME
375 Silas Creek Parkway I Winsron-Salem, NC 27127
[phone] T �[phone] F

O20F W ATE9OG
H y
� r
o �
Office Use Only:
Corps ac[ion ID no.
DWQ project no.
Form Version 1.4 January 2009
Pre-Construction Notification (PCN) Form
A. Applicant 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. 14 or General Permit (GP) number. GC 3886
1 c. Has the NWP or GP number been verified by the Corps? ❑ Yes � No
t d. Type(s) of approval sought irom the DWQ (check all that apply):
� 401 Water Quality Certification — Regular ❑ Non-404 Jurisdic6onal General Permit
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorizafion
1 e. Is this notfication solely for the record For the record only for DWQ For the record only for Corps Permit:
because wrilten approval is not required? 401 Certification:
❑ Yes ❑X No ❑ Yes ❑X No
1f. Is paymeM iMo a mitigation bank or in-lieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation bank � Yes � No
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 Concem (AEC)? ❑ Yes � No
2. Project Information
2a. Name of project: Pipe Replacement on SR 2848 Panther Lane
2b. County: Davidson
2c. Nearest municipality ! town: Thomasville
2d. Subdivision name:
2e. NCDOT only, T.I.P. or state project no: 9C.029110
3. Owner Infortnation
3a. Name(s) on Recorded Deed: NCDOT Division 9
3b. Deed Book and Page No.
3c. Responsible Party (for LLC if Mr. Pat Ivey, P.E.
applicabie):
3d. Street address: 375 Silas Creek Pkwy
3e. City, state, zip: Winston-Salem, North Carolina 27127
3f. Telephone no.: [phone]
3g. Fax no.: [phone]
3h. Email address: [e-mail]
Page 1 of 10
PCN Form — Version 1.4 January 2009

4. Applicant Infortnation ('rf different from owner)
4a. Applicant is: ❑ Agent ❑X Other, specify: Division Environmental Specialist
4b. Name: Stephanie Braquet
4c. Business name North Carolina Department of Transportation
(if applicabie):
4d. Street address: 375 Silas Creek Pkwy
4e. City, state, zip: WinstonSalem, North Carolina 27127
4f. Telephone no.: [phone]
4g. Fax no.: [phone]
4h. Email address: [e-mail]
5. AgentlConsuifant Infortnation (if applicable)
5a. Name:
5b. Business name
(if applicable):
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
5f. Fau no.:
5g. Email address:
Page 2 of 10

B. Project Information and Prior Project History
1. Properly Identification
1a. Property identification no. (tax PIN or parcel ID):
1 b. Site coordinates (in deamal degrees): Latitude: 35.8415 Longitude: -80.1405
1c. Propertysize: 2 acres
2. Surface Waters
2a. Name of nearest body of water to proposed project: Hamby Creek
2b. Water Quaiity Classification of nearest receiving water: C
2c. River basin: Yadkin/Pee-Dee
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 exis6ng site is an unpaved, gravel road that needs to be widened and paved. There is a reinforced concrete pipe rartying Hamby Creek under thi
road. The area is ruraVagricukural.
3b. List the total estimated acreage of all existing weUands on the property: 0
3c. List the total estimated linear feet of atl existing streams (intermittent and perennial) on the property: 60
3d. Explain the purpose of the proposed project:
Projec[ purpose is to replace an eadsting 30" x 50' 2inforced concrete pipe with a 36" x 60' comgated metal pipe and also widen and paved the road.
3e. Describe the overall project in detail, including the type of equipment to be used:
Standard conshuction equipment will be used.
4. Jurisdictional Determinations
4a. Have jurisdidional wetland or stream determinations by the � Yes � No ❑ Unknown
Corps or State been requested or obtained for this property /
ro ect includin all rior hases in the asY? Comments:
4b. If the Corps made the jurisdictional determination, what type � preliminary ❑ Final
of determination was made?
4c. If yes, who delineated the jurisdicfional areas? Agency/Consultant Company:
Name (ff known): Other.
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5. Project History
Sa. Have permits or certifications been requested or obtained for �Yes � No ❑ Unknown
this project (including all prior phases) in the pasY?
5b. If yes, euplain in detail according to "help file' instructions.
6. Future Project Plans
6a. Is this a phased project? ❑ Yes � No
6b. If yes, explain.
Page 3 of 10
PCN Fortn — Version 1.4 January 2009

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 impad Type of impact Type of wefland Forested Type of jurisdiction Area of
number Corps (404,10) or impact
Permanent (P) or DWQ (401, other) (acres)
Tem ora T
W1 - Choose one Choose one Yes/No -
1�YL - Choose one Choose one Yes/No -
Nl3 - Choose one Chowe one YeslNo -
N/¢ - Choose one Choose one YeslNo -
V1I5 - Choose one Choase one YeslNo -
y� - Choose one Choase one YeslNo -
2g. Total Wetland Impacts:
2h. Comments:
3. Stream Impacfs
If there are perennial or intermitter�t stream impacts (inGuding 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 (PER) or Type of Average Impact
number intertnittent (IN'I)? jurisdiction stream length
Permanent (P) or width Qinear
Temporary (T) �fe�� feet)
S1 T FII Hamby Creek PER Corps 4 8
$2 P Culvert Hamby Creek PER Corps 4 10
S3 - Choose one - -
S4 - Choose one - -
S5 - Choase one - -
S6 - Choose ane - -
3h. Total sfream and tributary impacts ta
3i. Comments:
Page 4 of 10
PCN Form — Version 1.4 January 2009

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 individuall list all o en water im acts below.
4a. 4b. 4c. 4d. 4e.
Open water Name of waterbody
impact number (if applicable) Type of impact Waterbody Area of impact (acres)
Permanent (P) or type
Tem ora
01 - Choase one Choose
p2 - Chowe one Choose
03 - Choose one Choose
pq - Choase one Choose
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If ond or lake constructio� ro osed, then com lete the chart below.
5a. 5b. Sc. Sd. 5e.
Pond ID number Proposed use or WeUand Impacts (acres) Stream Impacts (f�t) Upland
purpose of pond (acres)
Flooded Filled Expvated Flooded Filled Excavated
p1 Choose one
p2 Choose one
5f. Total:
5g. Comments:
Sh. Is a dam high hazard pertnit required? ❑ Yes � No If yes, permit ID no:
5i. Expected pond surtace area (acres):
5. Size of pond watershed (acres):
Sk. 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 buifer impacts
below. If an im acts re uire miti a6on, then ou MUST fill out Section D of this form.
6a. Project is in which protected basin? ❑ Neuse � Tar-Pamlico � Catawba ❑ Randleman ❑ Other:
6b. 6c. 6d. 6e. 6f. 6g.
Buffer Impact Reason for impact Stream name Butfer Zone 1 Zone 2
number— mitigation impact impact
Permanent (P) or required? (square (square
Tem ora feet feet
61 - Yes/No
B2 - YeslNo
B3 - Yes/No
64 ' Yes/No
B5 - YeslNo
B6 - YeslNo
6h. Totai BufFer Impacts:
6i. Comments:
rage a ot � u

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1 a. Specificaliy describe measures taken to avoid or minimize the proposed impacts in designing project.
The curteM pipe is undersized and is being replaced wiM the appropriatety sized cortugated metal pipe. NCDOT is extending the pipe 10' in length to
avoid over-widening the channel at the out let end.
1b. Specifirally describe measures taken to avoid or minimize the proposed impacts through consWction techniques.
NCDOT BMPs for Sediment and Erosion Control will be used.
2. Com ensa Miti tion for Im acts W Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for � Yes �X No
impacts to Waters of the U.S. or Waters of the State?
2b. If yes, mitigation is required by (check all that apply): ❑ DWQ ❑ Corps
❑ Mitigation bank
2c. If yes, which mibgation option will be used for this ❑ payment to in-lieu fee program
project'?
❑ Permittee Responsible Mitigation
3. Com lete if Usin a Miti ation Bank
3a. Name of Mitigation Bank:
Type: Choose one Gluantiry:
3b. Credits Purohased (attach receipt and letter) Type: Choose one Quantity:
Type: Choose one Quantity:
3c. Comments:
4. Com lete if Makin a Pa ent to In-lieu Fee Pro ram
4a. Approval letter from in-lieu fee program is attached. ❑ Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature: Choose ane
4d. Buffer mitigation requested (DWQ only): square feet
4e. Riparian wetland mitigation requested: acres
4f. Non-riparian wetland mfigation requested: acres
4g. Coastal (tidal) wetland mkigation requested: acres
4h. Comments:
5. Complete if Using a Pertnittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 6 of 10
PCN Form — Version 1.4 January 2009

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a. Will the projed result in a� impact within a protected riparian buffer that requires
buffer mitigation? ❑ Yes �X 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.
Bc. 6d. 6e.
Zone Reason for impact Total impact Mukiplier 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 restoretion, payment into an approved in-lieu fee fund).
6h. Comments:
Page 7 of 10

E. Stortnwater 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 iderdfied � Yes � No
within one of the NC Ri arian Bulfer Protection Rules?
1 b. If yes, then is a diffuse flow plan inGuded? If no, explain why.
❑ Yes � No
2. Stormwaier Mana ement Plan
2a. What is the overall perceM imperviousness of this project? o�
2b. Does this ro'ect re uire a Stormwater Mana ement Plan? ❑ Yes � No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
There will be no new impervious surface as a result of the projed.
2d. If this project DOES require a Stortnwater Management Plan, then provide a brief, narrative description of the plan:
2e. Who will be responsible for the review of the Stormwater ManagemeM Plan? wA
3. Certified Local Govemment Stormwater Review
3a. In which local ovemmeM's'urisdidion is this ro'ect?
❑ Phase II
3b. Which of the following locally-implemented stormwater management programs ❑ NSW
aPP�Y i�edc all that aPp1Y): ❑ 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 foliowing state-implemented stormwater management programs apply �ORW
(check all that appty): ❑Session Law 2006-246
❑Other:
4b. Has the approved Stormwater Management Plan with proof of approval been � Yes ❑ No
attached?
5. DWQ 401 Unit Stortnwater Review
5a. Does the Stormwater Management Pian meet the appropriate requirements? � Yes � No
Sb. Have all of the 401 Unit submittal requirements been meY? � Yes � No
Page 8 of 10
PCN Form — Version 1.4 January 2009

F. Supplementary Information
7. Environmental Documentation (DWQ Requirement)
ta. Does the project involve an expenditure of public (federaVstatellocal) funds or the � Yes ❑ No
use of public (federal/state) land?
'I 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 .0500j, Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards, ❑Yes 0 No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b. Is this an after-the�fad permit application? ❑ Yes ❑X 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 reasonabiy anticipated future impacts) result in � Yes 0 No
additional development, which could impad 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.
Indirec[ and cumulative impaIX analysis is e�eIXed Por pipe rep�acement.
4. Sewage Disposal (DWQ Requirement)
4a. Clearty detail the ultimate treatment methods and disposition (non-discharge or discharge) of wastewater generated from
NiA the proposed project, or availabie rapacity of the subjeet facility.
Page 9 of 10
PCN Form — Version 1.4 January 2009

5. Endangered Species and Designated Cridcal Habitat (Corps Requirement)
5a. Will this projed occur in or near an area with federally protected species or
habitat? ❑ Yes ❑X No
Sb. Have you checked with the USFWS conceming Endangered Speaes Act � Yes �X No
impacts?
Sc. If yes, indipte the USFWS Field OTfice you have contaded. -
Sd. What data sources did you use to determine whether your site would impad Endangered Species or Designated Critical
Habitat?
North Carolina Natural Heritage database
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitaY? ❑ 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 preserva6on � 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 archeologipl resources?
NCDOT CuKural Resources Group reviewed the project for effects. It was determined that there would be'no effed' on Archaeolagy or Historic
Archi(ec[ure. Reviews are available upon request.
8. Flood Zone Designation (Corps Requirement)
Sa. Will this project occur in a FEMA-designated 100-year floodplain? ❑ Yes 0 No
Sb. If yes, explain how project meets FEMA requirements:
N/A
8c. What source(s) did you use to make the floodplain determination?
FEMA Floodplain mapping
Stephanie Braquet, NCDOT Division 9 '
DES 08/1912016
ApplicanUAgenYs Printed Name plicant/Ag n ignature Date
(AgenPs ignaNre is valid on an authoriza8on
letter from the a Iica rovided.
Page 10 of 10

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Construction Sequence— Replace existing pipe: SR 2848 Panther Lane — Davidson County
1. Close one lane at a time.
2. Instail erosion control devices at each quadrant.
3. Block upstream flow with impervious structure. Use pump around method or pipe around and
dewater work area.
4. Remove road fill and existing pipe.
5. Excavate to sufficient depth to allow 1 foot (or 20 percent burial of pipe, if no bedrock is
encountered) and install new pipe from box to end of pipe
6. eackfill pipe and place rip rap stabilization and vegetate.
7. Notify landscape department for final seeding and mulching.
8. Complete road greding and pave roadway.
9. Site conditions and weather may alter these plans.
10. Construction time at permitted location to be 1 week.
11. If there are any questions, call Phillip Callahan, TS II at Davidson Maintenance at 336-224-3200

SINGLE PIPE REPLACEMENT
PIPE SIZE: 4 " '
TYPE: CMP
NORTH
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STREAM BED �
STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
DIVISION 9
DAVIDSON COUNTY
f:l:iii[:3
WATER SURFACE
..dE LAID 1' BELOW STREAM BED
OR
ON GRADE (IF BEDROCK IS PRESENT)
ARMOR @ OUTLET WITH THE APPROPRIATE CLASS OF RIP RAP FOR EROSION PROTECTION.

FILL_
STATION =0+00
6
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EXISTING: 50'- 36" RCP
PROPOSED: 60' - 48" CMP
COVER: MIN2'
DRAWN BY: TPC
CROSS SECTION
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RIGHT-OF-WAY
SHLDR f fi�, � SHLDR
�, 8, PAVEMENT WIDTH 0'-8'
18'
PLAN VIEW
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DRAINAGE PERMIT STA. 0+00
COUNTY: DAVIDSON
SR 2848
NAME: PANTHER LANE
DRAWING 1 OF 1

Northern Lon¢-Eared Bat 4(dl Rule Streamlined on ultation Form
Federal agencies should use this form for the optional streamlined consultation framework for the northem long-eazed
bat (NLEB). This framework allows federal agencies to rely upon the U.S. Fish and Wildlife Service's (L7SFWS)
January 5, 2016, intra-Service Programmatic Biological Opinion (BO) on the fmal 4(d) rule for the NLEB for section
7(ax2) compliance by: (1) notifying the USFWS that an action agency will use the streamlined framework; (2)
describing the project with sufficient detail to support ttte requued determination; and (3) enabling the USFWS to track
effects and determine if reinitiation of consultation is required per 50 CFR 402.16.
This form is not necessary if an agency detertnines that a proposed action will have no effect to the NLEB or if the
USFWS has concurred in writing with an agency's dete�mination that a proposed action may affect, but is not likely to
adversely affect the NLEB (i.e., the standard informal consultation process). Actions that may cause prohibited
incidental take requ've separate formal consultation. Providing this information dces not address secfion 7(a)(2)
compliance for any other listed species.
Information to Determine 4(d) Rule Compliance: YES NO
1. Does the project occur wholly outside of the WNS Zone 1? ❑ x
2. Haue you contacted the appropriate agencyZ to determine if yow project is near x �
known hibernacula or maternity roost irees?
3. Could the project dishvb hibemating NLEBs in a known hibernaculum? ❑ x
4. Could the project aker the entrance or interior environment of a known � X
hibemaculum?
5. Does the project remove any trees within 0.25 miles of a known hibernaculum at � X
any time of year?
6. Would the project cut or deslroy known occupied maternity roost trees, or any
other trees within a 150-foot radius from the maternity roost tree from June 1 � x
throu Jul 31.
You are eligible to use this form if you have answered yes to question # 1�yes to question #2 �no to questions 3,
4, 5 and 6. The remainder of the form will be used by the USFWS to track our assumptions in the BO.
Agency and AppGcant� (Name, Email, Phone No.): NCDOT Division �
Stephanie Braquet, scbraquetnncdot.gov, [phone]
Proiect Name: Dauidson County-Panther Lane
Project Location (include coordinates if known): 35.8415N -80.1405W
Basic Project Description (provide narrative below or attach additional information): NCDOT will replace
and undersized reinforced concrete pipe (RCP) with a larger sized corrugated metal pipe (CMP). We will also
widen and pave the gravel road.
1 http://www.fws.gov/midwesUendangered/mammals/nleb/pdf/WNSZone.pdf

Z See http://www.fws.gov/midwest/endangered/mammals/nleb/nhisites.html
3 If applicable - only needed for federal actions with applicants (e.g., for a permit, etc.) who are party to the coasultarion.
General Project Informalion YES NO
A¢encv Determination:
By signing this form, the action agency determines that this project may affect the NLEB, but that any
resulting incidental take of the NLEB is not prohibited by the final 4(d) rule.
If the USFWS does not respond within 30 days from submittal of this form, the action agency may presume
that its determination is informed by the best available information and that its project responsibilities under
7(a)(2) with respect to the NLEB are fulfilled through the USFWS January 5, 2016, Programmatic BO. The
action agency will update this determination annually for multi-year activities.
The action agency understands that the USFWS presumes that all activiries are implemented as described
herein. The action agency will promptly report any departures from the described activities to the appropriate
USFWS Field Office. The action agency wiil provide the appropriate USFWS Field Office with the results of
any surveys conducted for the NLEB. Involved parties will promptly norify the appropriate USFWS Field
Office upon finding a dead, injured, or sick NLEB.
Signature:
Date Submitted: � Iq 2D1Le
° Any acrivity that temporazily or permanently removes suitable forested habitat, including, but not limited to, tree removal from
development, energy production and lransmission, mining, agriculture, etc. (see page 48 of the BO).

5 Ifthe project removes less tUan 10 trees and the acreage is unknown, report the acreage as less than 0.1 acre.
b Ifthe activiTy includes tree clearing in June and July, also include those acreage in April to October.