20170832 Ver 1_PCN Form Submission_20170706

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 7/6/2017 12:41:28 PM (Start Event)
Accept by Carpenter,Kristi 7/6/2017 2:11:06 PM (DOT Initial Review)
* In BIMS as a filed as issued permit.
• The task was assigned to Carpenter,Kristi . The due date is: July 11, 2017 5:00 PM
7/6/2017 12:41 PM

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6fvlslaa of Water Resources
Pre-Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
June 28, 2017 Ver 1.8
*
Please note: fields marked with a red asterisk below are required. You will not be ab/e to submit the form until all mandatory questions are ans�red.
Below is a link to the DRAFT online help file. http://edocs.deq.nc.gov/WaterResources/0/doc/549884/Page1.aspx
A. Processing Information
County (or Counties) where the project is located:*
Guilford
Is this a NCDOT Project?*
C� Yes �' No
(NCDOT only) T.I.P. or state project number:
WBS #
WBS-17BP.7.C.5
(for NCDOT use only)
� 1a. Type(s) of approval sought from the Corps:*
rJ Section 404 Permit (wetlands, streams and waters, Clean Water Act)
r Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
1b. What type(s) of permit(s) do you wish to seek authorization?*
fJ Nationwide Permit (NWP)
r Regional General Permit (RGP)
Nationwide Permit (NWP) Number:
NWP Number Other:
List all MN nurrbers you are applying for not on the drop dow n list.
03 - Maintenance
1c. Type(s) of approval sought from the DWR:*
check all that apply
� 401 Water Quality Certification - Regular
� Non-404 Jurisdictional General Permit
r 401 Water Quality Certification - Express
r Riparian Buffer Authorization
1d. Is this notification solelyfor the record because written approval is not required?
For the record only for DWR 401 Certification:
I For the record only for Corps Permit:
1e. Is payment into a mitigation bank or in-lieu fee program proposed for mitigation of impacts?
*
C•' Yes !" No
C•' Yes C' No

If so, attach the acceptance letter from rritigation bank or in-lieu fee program
C' Yes C•' No
1f. Is the project located in any of NC's twenty coastal counties?*
C' Yes �' No
B. Applicant Information
1a. Who is the Primary Contact?*
I Nicole Thomson
1b. PrimaryContact Email:*
[e-mail]
1c. PrimaryContact Phone:*
(xxx)xxx-xxxx
[phone]
1d. Who is applying for the permit?
r Owner r Applicant (other than owner) rJ AgenUConsultant
(Check all that apply)
2. Owner I nformation
2a. Name(s) on recorded deed:
2b. Deed book and page no.:
2c. Responsible party:
(for Corporations)
2d.Address
Street Address
Address Line 2
�'
R�stal / Zip Code
2e. Telephone Number:
(xxx)xxx-xxxx
2f. Fax Number:
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
4. Agent/Consultant (if applicable)
4a. Name:
4b. Business Name:
(if applicable)
4c. Address
State / Rovince / F�gion
Country

Street Address
Address Line 2
��
Fbstal / Zip Code
4d. Telephone Number:
(xxx)xxx-xxxx
4e. Fax Number:
(xxx)xxx-xxxx
4f. Email Address:*
[e-mail]
AgentAuthorization Letter
Rease provide the Agent Authorization Letter iF you are subrritting this docurrent.
C.5_non-reporting_NW3_package. pdf
FlLE TYFE MJST BE FDF
State / R-ovince / F�gion
Country
2.98MB
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Culvert Replacement on NC 62
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:*
Liberty
1d. Driving directions*
If it is a new project and can not easily be found in a C�S rrapping system Rease provide directions.
UT to North Prong Stinging Quarter Creek; Ferguson Road, near 3295 NC 62, Liberty
2. Project Identification
2a. Property Identification Number:
(tax RNor parcel ID)
2b. Propertysize:
(in acres)
2c. Project Address
Street Address
Address Line 2
Qty
Fbstal / Zip Code
State / Rovince / F�gion
Country
2d. Site coordinates in decimal degrees
Please collect site coordinates in decimal degrees. Use betv�en 4-6 digits (unless you are using a survey-grade GPS device) after the decimal place as
appropriate, based on howthe location was determined. (For example, most mobile phones with GPS provide locational precision in decimal degrees to
map coordinates to 5 or 6 digits after the decimal place.)

Latitude:* Longitude:*
36.958406 -79.589982
ex:34208504 -77.796371
3. SurFace Waters
3a. Name of the nearest body of water to proposed project:*
North Prong Stinking Quarter Creek
3b. Water Resources Classification of nearest receiving water:*
WS-V: NSW
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Cape Fear
RiverBasin Lookup
4. Project Description
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:*
Ben Furr of ICA Engineering, Inc. (HDR�ICA) conducted field investigations within the project study area
on May 4 and June 16, 2016. One perennial stream (S1 - UT to North Prong Stinking Quarter Creek) was
identified within the project limits. North Prong Stinking Quarter Creek is classified as C, NSW. S1
substrate is dominated by sand upstream of the road and cobble/gravel downstream of the road. S1 is
appro�amately 8 to 10 feet wide and 1 to 2 feet deep, from stream bed to Ordinary High Water Mark
(OHWM). Indicators of OHWM include wrack lines and depositional benches. Mature hardwood
vegetation is present on both stream banks downstream of the road but lacking along the stream banks
upstream of the road. The project is in the Jordan Lake Watershed; therefore, the Jordan Lake Buffer
Rules apply to S1.
4b. Attach an 8 1/2 X 17 excerpt from the most recent version of the USGS topographic map indicating the location of the project site. (for
DWR)
C7ick the upload button or drag and drop files here to attach docurrent
RCBC 40 2053 Guilford USGS Map.pdf 2.69M6
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4c. Attach an 8 1/2 X 11 excerpt from the most recent version of the published County NRCS Soil Survey map depicting the project site.
(for DWR)
aick the upload button or drag and drop files here to attach docurrent
RCBC 40 2053 Guilford Soil Map.pdf
Fle lype rrust be pdF
4d. List the total estimated acreage of all existing wetlands on the property:
4e. List the total estimated linear feet of all existing streams on the property:
(interrrittent and perennial)
4f. Explain the purpose of the proposed project:
2.04M6
4g. Describe the overall project in detail, including the type of equipment to be used:
4h. Please upload project drawins for the proposed project.
Qick the upload button or drag and drop files here to attach docurrent
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5. Jurisdictional Determinations

5a. Have the wetlands or streams been delineated on the propertyor proposed impact areas?*
C� Yes �' No �' Unknown
Comments:
� Delineated by Benjamin Furr
5b. If the Corps made a jurisdictional determination, what type of determination was made? *
C' Preliminary C' Approved C' Unknown
Corps AID Number:
Exarrple: SAV�2017-99999
5c. If 4a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Othe r:
Benjamin Furr
5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
�llA
Sd1. Jurisdictional determination upload
aick the upload button or drag and drop files here to attach docurrent
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6. Project History
6a. Have permits or certifications been requested or obtained for this project (including all prior phases) in the past?*
C' Yes �' No �' Unknown
7. Future Project Plans
7a. Is this a phased project?*
C' Yes C•' 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? This includes other separate and distant crossing for linear projects that require Department of the
Army authorization but don't require pre-construction notification.
D. Proposed I m pacts I nventory
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
r Wetlands r Streams-tributaries r Buffers
r Open Waters r Pond Construction
' 2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
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.

*' All Perennial or Intermittent streams must be verified by DWR or delegated local government.
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.
5. Pond or Lake Construction
If pond or lake construction is proposed, then complete the chart below.
6. Buffer Impacts (for DWR)
If project will impact a protected riparian buffer, then complete the chart below. Individually list all buffer impacts below.
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:*
Culvert replacement only.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
Culvert replacement only, under Corp and DWR permitting threshold.
' 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?
f Yes C' No
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
1a. Does this project require a Stormwater Management Plan?
C' Yes C' No
2. Diffuse Flow Plan
I 2a. Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian Buffer Protection
Rules?
C' Yes C' No
4c. Provide a brief narrative description of the stormwater management plan.
4d. Has a completed BMP Supplement Form with all required items been submitted for each stormwater BMP?
C•' Yes
C' No
G. Supplementary Information
1. Environmental Documentation
1a. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state) land?*
C' Yes �' No

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)? *
C' Yes �' No
2b. Is this an after-the-fact permit application?*
C' 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 (DWR Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in additional development, which could impact
nearby downstream water quality?*
C' Yes C•' No
3b. If you answered "no," provide a short narrative description.
Culvert replacement only.
4. Sewage Disposal (DWR Requirement)
4a. Describe, in detail, the treatment methods and dispositions (non-discharge or discharge) of wastewater generated from the
proposed project. If the wastewater will be treated at a treatment plant, list the capacity available at that plant.
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?*
C' Yes �' No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
C� Yes �' No
5c. If yes, indicate the USFWS Field Office you have contacted.
i Raleigh
5d. Is this a DOT project located within Division's 1-8?*
�' Yes
C' No
5i. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
USFWS website
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
C' Yes �' No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
web
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
Link to the State Historic Preservation Office Historic Properties Map (does not include archaeological data: http://gis.ncdcr.gov/hpoweb/

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 (e.g., National Historic Trust designation or properties significant in North Carolina history and archaeology)? *
C' Yes �' No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?*
web
7c. Historic or Prehistoric Information Upload
C7ick the upload button or drag and drop files here to attach docurrent
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8. Flood Zone Designation (Corps Requirement)
Link to the FEMA Floodplain Maps: https://msc.fema.gov/portal/search
8a. Will this project occur in a FEMA-designated 100-year floodplain?*
C' Yes C•' No
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination?*
web
Miscellaneous attachments not previously requested.
aick the upload button or drag and drop files here to attach docurrent
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Signature
*
rJ By checking the box and signing below, I certify that:
■ 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
i Transactions AcY');
■ I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic
Transactions AcY');
■ 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:*
April Norton
Signature
,�,���� �� /
Date
7/6/2017
Initial Review
Is this project a public transportation project?
C•' Yes C' No
Q�ly change this if the project has been reassigned.
Has this project met the requirements for acceptance in to the review process?*

C� Yes
C' No
i BIMS#Assigned*
20170832
Version#*
1
Reviewing Office *
Central Office - [phone]
Select Project Reviewer*
April Norton:eads\arnorton