20170837 Ver 1_PCN Form Submission_20170706

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 7/6/2017 1:44:52 PM (Start Event)
Accept by Carpenter,Kristi 7/6/2017 5:35:21 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: July 11, 2017 5:00 PM 7/6/2017 1:45 PM

�� �
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:*
Wayne
Is this a NCDOT Project?*
�' Yes �' No
(NCDOT only) T.I.P. or state project number:
U-5796
WBS #
54039.1. F D 1
(for f�1CDOT 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.
14 - Linear transportation
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?
*
l" Yes C•' 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?*
Chad Coggins
1b. Primary Contact Email:*
[e-mail]
1c. PrimaryContact Phone:*
(xxx)xxx-xxxx
[phone]
1d. Who is applying for the permit?
r Owner r% Applicant (other than owner) r AgenUConsultant
(Check all that apply)
2. Owner I nformation
2a. Name(s) on recorded deed:
NCDOT
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:
I(xxx)xxx-xxxx
2f. Fax Number:
(xxx)xxx-xxxx
2g. Email Address:*
I [e-mail]
3. Applicant Information (if different from owner)
3a. Applicant is:
G Agent
C' Other
If other please specify.
3b. Name:
Chad Coggins
3c. Business Name:
State / Rovince / F�gion
Country

(if applicable)
NCDOT Div 4
3d.Address
Street Address
PO Box 3165
Address Line 2
��
Wilson
Fbstal / Zip Code
27895
3e. Telephone Number:
[phone]
(xxx)xxx-xxxx
3f. Fax Number:
(xxx)xxx-xxxx
3g. Email Address:*
[e-mail]
State / R-ovince / F�gion
NC
Country
Wilson
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
U-5796 grade separated interchange at US 117 & SR 1120 (O'BERRY RD.)
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:*
Mount Olive
1d. Driving directions*
If it is a new project and can not easily be found in a C� rrepping system Rease provide directions.
i intersection of US 117 & SR 1120 (O'BERRY RD.) South of Goldsboro North of Mount Olive
2. Project Identification
2a. Property Identification Number:
(tax RN or parcel ID)
2b. Propertysize:
(in acres)
50
2c. Project Address
Street Address
Address Line 2
��
Fbstal / Zip Code
State / Rovince / F�gion
Country
2d. Site coordinates in decimal degrees
Please collect site coordinates in decimal degrees. Use between 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:*
35.26429 - 78.05303
ex:34.208504 -77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
UT to Brooks Swamp
3b. Water Resources Classification of nearest receiving water:*
WS-IV NSW
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Neuse
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:*
Forestry and Agriculture are the predominant land uses in the vicinity of this project. This site was designated as a
future interchange when US 117 was built in mid 1980's (project # R-91).
4b. Attach an 8 1/2 X 11 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
U5796 TOPO Map.pdf 1.26MB
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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 docurrem
Fle type rrust be pdF
4d. List the total estimated acreage of all existing wetlands on the property:
.11
4e. List the total estimated linear feet of all existing streams on the property:
(interrrittent and perennial)
0
4f. Explain the purpose of the proposed project:
The purpose of this project is to improve the safety by removing this at grade intersection and building a grade
separated interchange
4g. Describe the overall project in detail, including the type of equipment to be used:
SR 1120 will "flyover" US 117 and ramps will be built get on and off US 117 in both directions. Typical heavy
construction roadway equipment will be used.
4h. Please upload project drawins for the proposed project.
C7ick the upload button or drag and drop files here to attach docurrent
U-5796- Permit Drawing.pdf 1.09M6
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5. Jurisdictional Determinations

5a. Have the wetlands or streams been delineated on the propertyor proposed impact areas?*
C' Yes C' No C' Unknown
Comments:
A blueline shows up on soils and topo maps but no defined channel exists in
the field. Original plans when US 117 was built did not show any defined
channel on the upstream side of the road (eastside) only riprap lined
parallel base ditches that mainly carry roadway water. There are no
jurisdictional features or defined channels coming to R/W. On the
downstream side (westside) a parallel base ditch flows into a wetland system
as shown on original plans. A defined channel (point of origin) does not
begin until well beyond R/W. See attached stream forms. Took pics but they
are fuay
Sb. If the Corps made a jurisdictional determination, what type of determination was made? *
C' Preliminary C' Approved C•' Unknown
Corps AID Number:
6carrple: SAV�2017-99999
5c. If 4a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Othe r:
Chad Coggins
NCDOT DEO
5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5d1. Jurisdictional determination upload
C7ick 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 r 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):
rJ 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.
2a. Site #- Reason for 2b. Impact type * 2c. Type of wetland
impact
Site 1 Fill
N�p label (e.g. I�ad Qossing 1)
Site 1 excavation
N�p label (e.g. F�ad Qassing 1)
Site 1 MC
N�p label (e.g. R�ad Qossing 1)
Site 1 HC
N�p label (e.g. I�ad (7ossing 1)
P
F�rrranent (P� or Terrporary
��
P
F2rrranent (Pj or Terrporary
��
P
F2rrranent (Fj or Terrporary
i�
T
F�rrranent (Pj or Terrporary
��
2g. Temporary Wetland Impact
0.100
2g. Permanent Wetland Impact
0.033
2g. Total Wetland Impact
0.133
2h. Comments:
2d. Wetland name 2e. Forested 2f. 2g. Impact
Jurisdiction area
type
No Both 0.001
(404, 10) or C7�NR (acres)
(401, other)
No Both 0.004
(404, 10) or C�NR (acres)
(401, other)
No Both 0.028
(404, 10) or CNVR (acres)
(401, other)
No Both 0.100
(404, 10) or DdVR (acres)
(401, other)
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:*
Only very minor impacts are proposed

1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
All construction equipment will be staged and operated from upland areas. DOT will also install silt fencing to
protect the streams and wetlands adjacent to this project, and safety fencing will be used to delineate those
environmentally sensitive areas.
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?
C' Yes
C•' No
2b. If this project DOES NOT require Compensatory Mitigation, explain why:
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
1a. Does this project require a Stormwater Management Plan?
C� Yes
C' No
1b. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
All stormwater will be allowed to flow over grass shoulders and ditches. Project utilizes lateral base ditch (grass
swales to the max extent practicable). see attached drawings
1c. What is the overall percent imperviousness of this project?
%
1d. Who will be responsible for the review of the Stormwater Management Plan?*
r Certified Local Government
r DWR 401 & Buffer Permitting Branch
2. Diffuse Flow Plan
r DEMLR Stormwater Review
�7 DWR Transportation Permitting Branch
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
!•' No
If no, explain why:
although blueline on map no defined features exist in the field within R/W (see attached stream forms) All stormwater will be allowed to flow
over grass shoulders and ditches.
4c. Provide a brief narrative description of the stormwater management plan.
riprap dissipaters are used at the end of all pipe outlets to ensure diffuse flow. All velocities at pipe outlets as well as all ditch grades have
been analyzed to assure non erosive velocities see attached drawings.
4d. Has a completed BMP Supplement Form with all required items been submitted for each stormwater BMP?
C' Yes
�' No
5. DWR 401 Stormwater Review
5a. Is the Stormwater Management Plan (including BMP Supplemental Forms and Operation and Maintenance Agreements) attached?
C' Yes �' No
Stormwater Management Plan Upload
Gick the upload button or drag and drop files here to attach docurrent
file type rrust be pdf
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
1b. 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 (North Carolina) Environmental PolicyAct (NEPA/SEPA)?*
C� Yes �' No
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
NEPAor SEPAfinal approval letter.)*
C' Yes C•' No
Comments:*
MCDC on file
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 C•' No
2b. Is this an after-the-fact permit application?*
C' Yes C•' 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.
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 C•' No
5c. If yes, indicate the USFWS Field Office you have contacted.
5d. Is this a DOT project located within Division's 1-8?*
C� Yes
C' No

5i. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
i NCNHP database plus onsite assessment
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
C' Yes C•' No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
no streams present
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 historyand archaeology)?*
�' Yes C' No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources? *
HEU clearance
7c. Historic or Prehistoric Information Upload
C7ick the upload button or drag and drop files here to attach docurrent
WayneUS1170'BerryNoSurvey.pdf 1.87MB
U-5796 Wayne No Archaeological Survey Required Form.pdf 1.36MB
Fle rrust be FiJF
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 �' No
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination?*
� NC floodmap
Miscellaneous attachments not previously requested.
aick the upload button or drag and drop files here to attach docurrent
U5796 Environmental Map.pdf 1.29MB
NC DWQ Stream Id Form Site 1.pdf 62.44KB
NC DWQ Stream Id Form Site 2.pdf 63.83K6
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Signature
*
� 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
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.
I Full Name:*
Chad Coggins
Signature
��r�l� ��a�r fr�!�I
Date
7/6/2017
Initial Review
Is this project a public transportation project?
C� Yes C' No
Qily 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
BIMS # Assigned*
20170837
Version#*
Reviewing Office *
Central Office - [phone]
Select Project Reviewer*
Rob Ridings:eads\rgridings