20161129 Ver 1_Signed PCN_20161116

Office Use Oniy:
Corps action 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:
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 ali 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 For the record only for Corps Permit:
because written approval is not required? 401 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. Projectlnformation
2a. Name of project: B-5763, Bridge # 129 Replacement on SR 2407 over Sandy Creek Trib 3
2b. County: Randolph
2c. Nearest municipality / town: Liberty
2d. Subdivision name: N/A
2e. NCDOT only, T.I.P. or state WgS Element No: 45719.1.1 / TIP: B-5763
project no:
3. Owner Information
3a. Name(s) on Recorded Deed: NCDOT Highway Division 8
3b. Deed Book and Page No. N(A
3c. Responsible Party (for LLC if Art King
applicable):
3d. Street address: 902 N. Sandhill Blvd.
3e. City, state, zip: Aberdeen, NC 28315
3f. Telephone no.: 910-944-2344
3g. Fax no.: 910-944-5623
3h. Email address: ackino(�Dncdot.gov
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PCN Form — Version 1.4 January 2009

4. Applicant Information (if different from owner)
4a. Applicant is: I❑ Agent ❑ Other, specify:
4b. Name:
4c. Business name
4d. Streetaddress:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. AgenUConsultant Information (if applicable)
5a. Name:
Sb. Business name
5c. Street address:
5d. City, state, zip:
5e. Telephone no.:
Sf. Fax no.:
5g. Email address:
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B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID):
1 b. Site coordinates (in decimal degrees):
1c. Propertysize:
2. Surtace Waters
2a. Name of nearest body of water to proposed project:
2b. Water Quality Classification of nearest receiving water:
2c. River basin:
N/A
Latitude: 35.ssas2s
2.2 acres (within project area)
Sandy Creek
WS III
Cape Fear
Longitude: as.stst90
3. ProJect Descriptfon
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 site consists of a structurally deficient bridge along a two lane section of state road. The surrounding land is a mixture
of agricultural, rural residential, and forested land.
3b. List the total estimated acreage of all existing wetlands on the property: +/- 0.16 acres
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the propertv: +/-180 LF
3d. Explain the purpose of the proposed project:
The purpose of the project is to replace the existing structure with 3 barrel @ 10'x8' cast-in-place- RCBC box culvert with
top bevel buried 1' with 1' sills in low flow barrels and 2'sill in floodplain barrel. See attached justification letter.
3e. Describe the overall project in detail, including the type of equipment to be used:
Traffic will be detoured off-site and erosion and sedimentation control measure will be installed. Water will be diverted
around the construction area and the old bridge will be removed. The proposed 3 barcel @ 10'x8' cast-in-place- RCBC
will be installed. Water will be pumped around the work area during construction by stalled impervious dikes upstream
and downstream of the existing bridge. Pumped water between dikes will be directed into a special stilling basin.
Equipment to be used includes a track hoe, dump truck, paving equipment, pumps, and various hand tools.
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (inGuding all prior phases) in the past?
4b. If the Corps made the jurisdictional determination, what type
of determination was made?
4c. If yes, who delineated the jurisdictional areas?
Name (if known):
❑ Yes � No ❑ Unknown
Comments:
❑ Preliminary ❑ Final
Agency/Consultant Company: Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5. Project
Sa. Have permits or certifications been requested or obtained for � yes
this project (including all prior phases) in the past7
Sb. If yes, expiain in detail according to "help file" instructions.
6. Future Project Plans
6a. Is this a phased projec
6b. If yes, explain.
❑ Yes
Page 3 of 10
11 .
►� .
❑ Unknown
PCN Form — 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
2. Wetland Impacts
❑ Pond Construction
If there are wetland impacts proposed on the site, then complete this question for each wetland area
�a. zb. 2c. 2d. 2e. 2f,
Wetland impact Type ofjurisdiction
number Type of impact Type of Forested Corps (404, 10) or Area of impact
Permanent (P) or wetland DWQ (401, other) (acres)
Tem ora if known
- Choose One Choose one Yes/No - p
2g. Total wetland impacts 0
2h. Comments: No wetland impacts are proposed for this project.
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 of jurisdiction Average stream Impact
number
Permanent (P) or
Site 1- P Culvert Sandy Creek
Trib 3
Site 1— P Bank Sandy Creek
Stabilization Trib 3
Site 1- p Scour Hole Sandy Creek
Repair/protection Trib 3
(PER) or
intermitte
nt (INT)?
PER
PER
PER
Corps/DWR
Corps/DWR
Corps/DWR
width length
(feet) (linear
feet)
25 41
25 21
25 � 21
Site 1-T De-watering PER " 25 23
3h. Total stream and tributary impacts 106
3i. Comments: Of the 106 LF of stream impacts 83 LF are associated with permanent impacts to the stream. Of that amount
41 LF are impacts that requires mitigation (the ILF approval letter is attached) the remaining impacts are for the purpose of
bank stabilization, Scour hole repair, and culvert outlet protection. 23 LF of temporary impacts are associated with the
impervious dikes that will be used upstream and downstream for purposes of de-watering.
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 imqacts below.
4a. 4b.
Open water Name of
impact number— waterbody
Permanent (P) or (if applicabie)
01 Choose one
Type of impact
Choose One
4g. Comments: There are no open waters within the project
Waterbody type
Choose
4f. Total open water impacts
area
Page 4 of 10
4e.
Area of impact (acres)
Q
0
PCN Form — Version 1.4 January 2009

5. Pond or Lake Construction
If ond or lake construction ro osed, then com lete the chart below.
5a. 5b. 5c. Sd. 5e.
Wetland Impacts (acres) Stream Impacts (feet) Upland
Pond ID Proposed use or (acres)
number purpose of pond
Flooded Filled Excavated Flooded Filled Excavated Flooded
Choose One
Choose One
5f. Total 0 0 0 0 0 0 0
5g. Comments: No pond or lake construction is proposed
5h. Is a dam high hazard permit required?
❑ Yes ❑ No If yes, permit ID no:
5i. Expected pond surface area (acres): N/A
5j. Size of pond watershed (acres): N/A
5k. Method of construction: N/A
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 im acts re uire miti ation, then ou MUST fill out Section D of this form.
6a.Project is in which protected basin? ❑ Neuse ❑ Tar-Pamlico 0 Catawba � Randleman 0 Other:
6b. 6c. 6d. 6e. 6f. 6g.
Buffer impact
number— Reason Buffer mitigation required? Zone 1 impact Zone 2 impact
Permanent (P) or for Stream name (square feet) (square feet)
Tem ora T im act
Choose one Yes/No
6h. Total buffer impacts
6i. Comments:
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D. Impact Justification and Mitigation
7. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
The proposed project will remove and replace a structuraliy deficient bridge with a 3 barrel @ 10' x 8' cast-in-place
RCBC box culvert. Roadway approach work is minimized as much as is practical to reduce the overail project footprint.
An off-site detour will be employed to avoid the need for a temporary parallel structure. Bank stabilization will be
minimized to those areas where deemed necessary
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Erosion and sedimentation BMPs witl be installed prior to construction. Impacts will be minimized by strict enforcement of
Best Management Practices for the protection of surtace waters and restrictions against the staging of equipment in or
adjacent to water of the US, and coordination with the Division Environmental O�cer.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for � Yes ❑ 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 mitigation option will be used for this
project? � Payment to in-lieu fee program
❑ Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
Type: Choose one Quantity N/A
3b. Credits Purchased (attach receipt and letter) Type: Choose one Quantity N/A
Type: Choose one Quantity N/A
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: 41 linear feet
4c. If using stream mitigation, stream temperature: warm
4d. Buffer mitigation requested (DWQ only): 0 square feet
4e. Riparian wetland mitigation requested: 0 acres
4f. Non-riparian wetland mitigation requested: 0 acres
4g. Coastal (tidal) wetiand mitigation requested: 0 acres
4h. Comments: N/A
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.
Page 6 of 10

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
Zone 2
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:
Page 7 of 10

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
within one of the NC Riparian Buffer Protection Rules? ❑ Yes � No
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? 33%
2b. Does this project require a Stormwater Management Plan? � Yes ❑ No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
A stormwater management plan is inciuded within the permit package. The project will be completed in accordance with
the NCDOT BMP manual to the maximum extent practicable. Construction stormwater management will comply with NCS
000250.
2e. Who will be responsible for the review of the Stormwater Management Plan? DWR 401 Unit
3. Certified Local Government Stormwater Review
3a. In which local govemmenYs 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 Pian 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 ali of the 401 Unit submittal requirements been met? ❑ Yes ❑ No
Page 8 of 10
PCN Form — Version 1.3 December 10, 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 (federai/state) land? � Yes ❑ No
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 (NEPAISEPA)?
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 Surtace 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.
This project is a bridge replacement along the existing alignment and will not increase access to nearby properties.
4. Sewage Disposal (DWQ Requirement)
4a. Clearly detaii the ultimate treatment methods and disposition (non-discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility.
It is not anticipated that this project will generate any wastewater as it is a roadway project.
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 USFVVS concerning Endangered Species Act
impacts? ❑ Yes ❑ No
5c. If yes, indicate the USFWS Field Office you have contacted.
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
On site survey by authorized NCDOT staff (check sheet attached)
raye a or iu
PCN Form — Version 1.3 December 10, 2008 Version

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?
The proposed project takes place in Randolph County which is not near any coastal or tidal habitat that would support EFH
(i.e. salt marshes, oyster reefs, etc.).
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?
NCDOT PEDA screening. (survey results attached)
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: Please refer to the Culvert Survey Report
8c. What source(s) did you use to make the floodplain determination? FEMA FIRM Maps
Art C. King / �yL C7 .' 11-09-16
C_/�`�
ApplicanUAgenYs Printed Name ApplicantlAgenPs Sig tur Date
(AgenYs signature is valid only if an authorization letter from the applicant
is rovided.
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