20161267 Ver 1_PCN_20161220

Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.3 Dec 10 2008
Pre-Construction Notification (PCN) Form
A. A licant Information
1. Processing
1 a. Type(s) of approval sought from the
Corps: � Section 404 Permit ❑ Section 10 Permit
1b. Specify Nationwide Permit (NWP) number: 14 or General Permit (GP) number:
1c. 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: Pipe Installations in Chowan Swamp Game Land
2b. County: Gates County
2c. Nearest municipality / town: Eure
2d. Subdivision name: n/a
2e. NCDOT only, T.I.P. or state 36249.3664
project no:
3. Owner Information
3a. Name(s) on Recorded Deed: State of North Carolina - NC Wildlife Resources Commission
3b. Deed Book and Page No. 272/58
3c. Responsible Party (for LLC if
applicable):
3d. Street address: 116 W. Jones St.
3e. City, state, zip: Raleigh, NC 27602
3f. Telephone no.:
3g. Fax no.:
3h. Email address:
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4. Applicant Information (if different from owner)
4a. Applicant is: ❑ Agent � Other, specify: Division 1 Environmental Specialist
4b. Name: Paul Williams
4c. Business name
(if applicable):
4d. Street address: 113 Airport Drive Suite 100
4e. City, state, zip: Edenton, N.C. 27932
4f. Telephone no.: 1-252-482-1861
4g. Fax no.: 1-252-482-8722
4h. Email address: [e-mail]
5. Agent/Consultant Information (if applicable)
5a. Name:
5b. Business name
(if applicable):
5c. 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
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID): 6011750205
Latitude: 36.445058°
1 b. Site coordinates (in decimal degrees): Longitude: - 76.916234°
(DD.DDDDDD) (-DD.DDDDDD)
1 c. Property size: 0.1 acres
2. Surface Waters
2a. Name of nearest body of water (stream, river, etc.) to Beasley Branch
proposed project:
2b. Water Quality Classification of nearest receiving water: C;NSW
2c. River basin: Chowan
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:
Project area consist of Zebra Road on Chowan Swamp Game Land. Land use is conservaiton and timber production.
3b. List the total estimated acreage of all existing wetlands on the property:
6 acres in vicinity of sites
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property:
n/a in vicinity of the sites
3d. Explain the purpose of the proposed project:
Install 2 new 18" X 30' CAP's in roadway. Will enhance connectivity of jurisdictional wetlands in project area.
3e. Describe the overall project in detail, including the type of equipment to be used:
Proposed 18"X30' CAP's will be installed in roadway at 2 sites. Once pipes are in place and back filled, a new gravel
roadway surface and grassed shoulder will be established. The shoulders will be stabilized following NCDOT erosion control
BMP's. The work will be accom lished with excavator, backhoe, and dum trucks.
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property / � Yes ❑ No ❑ Unknown
project (including all prior phases) in the past?
Comments:
4b. If the Corps made the jurisdictional determination, what type � preliminary ❑ Final
of determination was made?
4c. If yes, who delineated the jurisdictional areas?
Name (if known): Paul Williams, Agency/Consultant Company: NCDOT
Div. 1 Environmental Specialist 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 � No ❑ Unknown
this project (including all prior phases) in the past?
5b. If yes, explain in detail according to "help file" instructions.
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6. Future Project Plans
6a. Is this a phased project? ❑ Yes � No
6b. If yes, explain.
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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 impact Type of jurisdiction
number — Type of impact Type of wetland Forested (Corps - 404, 10 Area of impact
Permanent (P) or (if known) DWQ — non-404, other) (acres)
Tem ora T
Freshwater � Yes � Corps
W1 � P❑ T excavation Forested/Shrub 32 sq.ft.
Wetland ❑ No ❑ DWQ
Freshwater � Yes ❑ Corps
W2 � P❑ T excavation Forested/Shrub 32 sq.ft.
Wetland ❑ No ❑ DWQ
Freshwater � Yes ❑ Corps
W3 ❑ P� T hand clearing Forested/Shrub 60 sq.ft.
Wetland ❑ No ❑ DWQ
Freshwater � Yes ❑ Corps
W4 ❑ P� T hand clearing Forested/Shrub 60 sq.ft.
Wetland ❑ No ❑ DWQ
W5 ❑ P❑ T ❑ Yes ❑ Corps
❑ No ❑ DWQ
W6 ❑ P❑ T ❑ Yes ❑ Corps
❑ No ❑ DWQ
2g. Total wetland impacts <.01 acres
2h. Comments:
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 Impact
number - (PER) or (Corps - 404, 10 stream length
Permanent (P) or intermittent DWQ — non-404, width (linear
Temporary (T) (INT)? other) (feet) feet)
S1 ❑ P❑ T ❑ PER ❑ Corps
❑ INT ❑ DWQ
S2 ❑ P❑ T ❑ PER ❑ Corps
❑ INT ❑ DWQ
S3 ❑ P❑ T ❑ PER ❑ Corps
❑ INT ❑ DWQ
S4 ❑ P❑ T ❑ PER ❑ Corps
❑ INT ❑ DWQ
S5 ❑ P❑ T ❑ PER ❑ Corps
❑ INT ❑ DWQ
S6 ❑ P❑ T ❑ PER ❑ Corps
❑ INT ❑ DWQ
3h. Total stream and tributary impacts
3i. Comments: none
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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
02 ❑P❑T
03 ❑P❑T
04 ❑P❑T
4f. Total open water impacts
4g. Comments: None
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
P2
Sf. Total
5g. Comments: none
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 any impacts require mitigation, then you 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?
B1 ❑P❑T ❑Yes
❑ No
B2 ❑P❑T ❑Yes
❑ No
B3 ❑P❑T ❑Yes
❑ No
6h. Total buffer impacts
6i. Comments: none
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D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
Minimize pipe length to reduce impacts to adjacent wetlands.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
NCDOT's BMP's.
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: n/a
3b. Credits Purchased (attach receipt and letter) Type Quantity
3c. Comments: n/a
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: linear feet
4c. If using stream mitigation, stream temperature: ❑ warm ❑ cool ❑cold
4d. Buffer mitigation requested (DWQ only): square feet
4e. Riparian wetland mitigation requested: acres
4f. Non-riparian wetland mitigation requested: acres
4g. Coastal (tidal) wetland mitigation requested: 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.
n/a
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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).
n/a
6h. Comments: n/a
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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.
❑ Yes ❑ No
Comments:
2. Stormwater Mana ement Plan
2a. What is the overall percent imperviousness of this project? n/a %
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:
NCDOT will follow best management practices for soil and erosion control in compliance with N.C. Sediment and
Pollution Control Act and NCDOT NPDES permit.
❑ 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? Gates County
❑ Phase II
3b. Which of the following locally-implemented stormwater management programs ❑ NSW
apply (check all that apply): ❑ USMP
❑ Water Supply Watershed
� Other: N/A
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: ncdot
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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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)?
1c. 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 subject facility.
no waste water will be generated from this project
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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 ❑ No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act � Yes � No
impacts?
❑ Raleigh
5c. 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?
NC Natural Heritage Database - project sites occur near areas of RCW occurences, project sites occur in Nonriverine
Swamp Forest (Sweetgum Subtype)
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?
National Marine Fisheries Database
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?
NC State Historic Preservation Data
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: n/a
8c. What source(s) did you use to make the floodplain determination? NC Flood Maps
Paul Williams i 12/13/2016
Applicant/Agent's Printed Name ApplicanUAgent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant
is rovided.)
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