20170986 Ver 1_PCN Form Submission_20170808

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 8/8/2017 10:27:51 AM (Start Event)
Accept by Carpenter,Kristi 8/8/2017 11:36:16 AM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: August 11, 2017 5:00 PM
8/8/2017 10:28 AM

�� �
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:*
Rowan
Is this a NCDOT Project?*
C� Yes �' No
(NCDOT only) T.I.P. or state project number:
WBS #
176P.9.R.62
(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
�' Yes C' No
Acceptance Letter Attachment
Qick the upload button or drag and drop files here to attach docurrent
i SR 1221 - Bridge 236 - Division 9- STR - YD 05.pdf
FlLE IYFE MJST BE FDF
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?*
Amy Euliss
1b. PrimaryContact Email:*
[e-mail]
1c. PrimaryContact Phone:*
(xxx)xxx-xxxx
[phone]
1d. Who is applying for the permit?
� Owner rJ Applicant (other than owner) r AgenUConsultant
(Check all that apply)
2. Owner I nformation
2a. Name(s) on recorded deed:
NCDOT Division 9
2b. Deed book and page no.:
2c. Responsible party:
(for Corporations)
Pat Ivey, P.E. Division 9 Engineer
2d.Address
Street Address
375 Silas Creek Parkway
Address Line 2
�Y
Winston-Salem
Fbstal / Zip Code
27127
2e. Telephone Number:
(xxx)xxx-xxxx
[phone]
2f. Fax Number:
[phone]
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
3. Applicant Information (if different from owner)
61.31 KB
State / R-ovince / F�gion
NC
Country
United States

3a. Applicant is:
C' Agent
C' Other
If other please specify.
3b. Name:
Amy Euliss
3c. Business Name:
(if applicable)
NCDOT Division 9
3d. Address
Street Address
375 Silas Creek Parkway
Address Line 2
��
Winston-Salem
Fbstal / Zip Code
27127
3e. Telephone Number:
[phone]
(xxx)xxx-xxxx
3f. Fax Number:
[phone]
(xxx)xxx-xxxx
3g. Email Address:*
[e-mail]
State / Rovince / F�gion
NC
Country
United States
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Bridge to culvert replacement of Bridge No. 790236 on Bostian Road,
Rowan County, NC.
1b. Subdivision name:
(if appropriate)
NA
1c. Nearest municipality/town:*
Landis
1d. Driving directions*
If it is a new project and can not easily be found in a GPS rrapping system Rease provide directions.
Take I-40 West to I-85 South. Take I-85 South to Hwy 29 South. Take FMy 29 South turn left on Bostian Rd. The Bridge is located
approbmately 0.63 miles south on Bostian Rd.
2. Project Identification
2a. Property Identification Number:
(t�vc RN or parcel ID)
2b. Propertysize:

(in acres)
0.5 acre
2c. Project Address
Street Address
Address Line 2
(7iy
Fbstal / Zip Code
2d. Site coordinates in decimal degrees
State / FYovince / F�gion
Country
i 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:*
35.539877 -80.588076
ex:34208504 -77.796371
3. SurFace Waters
3a. Name of the nearest body of water to proposed project:*
Town Branch (Tributary to Cold Water Creek)
3b. Water Resources Classification of nearest receiving water:*
WS-IV
Surface Water Lookup
3c. What river basin(s) is your project located in?*
i Yadkin-PeeDee
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:*
The e�sting site is a bridge over Town Branch (Tributary to Cold Water Creek). The surrounding land is a mixture
of agricultural, rural residential, and forested areas.
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)
aick the upload button or drag and drop files here to attach docurrent
Figure 1_B-236_USGS.pdf 775.77KB
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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)
C7ick the upload button or drag and drop files here to attach docurrent
Figure 2_B-236_Soils legend.pdf 795.41 KB
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4d. List the total estimated acreage of all existing wetlands on the property:
0
4e. List the total estimated linear feet of all existing streams on the property:
(interrrittent and perennial)
145 LF perennial

4f. Explain the purpose of the proposed project:
I Replacing a structurally deficient single span bridge with 2@ 11'x9' Cast-In-Place RCBC's on a 90-degree skew.
4g. 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 measures will be installed. Water will be
diverted around the construction area and the old bridge will be removed. The proposed structure is a new culvert
2@ 11' X 9' RCBC cast in place on a 90-degree skew. The channel will then be excavated and realigned for low
flow shaping, and a floodplain bench with stabilization will be established on the right bank. Water will be diverted
around the work area during construction by installed impervious dikes upstream and downstream of the e�asting
bridge. Equipment to be used includes a track hoe, dump truck, paving equipment, pumps, and various hand
tools.
4h. Please upload project drawins for the proposed project.
IGick the upload button or drag and drop files here to attach docurrent
790236 Complete Set.pdf 1.73M6
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5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the propertyor proposed impact areas?*
G Yes C' No f" Unknown
Comments:
Delineations have not been verified by USACE or NCDWR
Sb. If the Corps made a jurisdictional determination, what type of determination was made? *
C' Preliminary C' Approved C•' Unknown
Corps AID Number:
6carrple: SAVw2017-99999
Sc. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Othe r:
Unknown
Mulkey, inc (now Caylx)
5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
Jurisdictional verification not requested by the USACE and DWR
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 �' 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.
NA

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 rJ Streams-tributaries
r Open Waters r Pond Construction
r Buffers
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.
Row 1
Row 2
Row 3
3a. Site # - 3b.lmpact
Reason for type
impact
1 P
N�p label (e.g. F2rrranent (P� or
13�ad Qossing 1) Terrporary (�
3c. Type of 3d. Stream 3e. Stream 3f. 3g. Stream 3h. Impact
impact name Type Jurisdiction width length
type
Culvert Town Perennial Both Average 48
BranCh F�rennial (� or � � (linear feet)
interrrittent (IfV�
1 P Bank Town
N�p label (e.g. F�rrranent (P� or Stabilizatio Branch
13�ad Qossing 1) Terrporary (� n
1 T Dewatering Town
fv�p label (e.g. F�rrrenent (P) or BranCh
R�ad Qossing 1) Terrporary (�
Perennial Both
F�rennial (� or
interrrittent (IfV�
Perennial Both
F2rennial (FH�) or
interrrittent (IN�
�` All Perennial or Intermittent streams must be verified by DWR or delegated local government.
3i. Total jurisdictional ditch impact in square feet:
0
3i. Total permanent stream impacts:
121
3i. Total temporary stream impacts:
23
3i. Total stream and tributary impacts:
144
(feet)
Average
11
(feet)
Average
11
(feet)
3j. Comments:
Of the 144 LF of stream impacts, 121 LF are associated with permanent impacts to the stream for the purpose of
culvert installation and floodplain bench stabilization. The 23 LF of temporary impacts are associated with
dewatering and work in the dry to install the bank stabilization.
73
(linear feet)
23
(linear feet)
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:*
The proposed project will remove and replace a structurally deficient bridge and replace it with a double box
culvert. Roadway approach work is minimized as much as is practical to reduce the overall project footprint. An off-
site detour will be employed to avoid the need for a temporary parallel structure. The proposed culvert slope is
1.00%, matching the e�sting stream bed slope of 1.00%. Native bed material shall be placed between the sills in
the culvert to provide a continuous lowflowchannel. Furtherjustification is provided in the stormwater
management plan. Bank stabilization will be minimized to those areas where deemed necessary
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
i Erosion and sedimentation BMPs will be installed prior to construction. Water will be diverted around the work area
to prevent sedimentation of downstream aquatic resources. Impacts will be minimized by strict enforcement of Best
Management Practices for the protection of surface waters, restrictions against the staging of equipment in or
adjacent to waters of the US and coordination (including a pre-construction meeting) with the Division
Environmental Supervisor.
I 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
2c. If yes, mitigation is required by (check all that apply):
r DWR �J Corps
2d. If yes, which mitigation option(s) will be used for this project?
r Mitigation bank �7 Payment to in-lieu fee program r Permittee Responsible Mitigation
4. Complete if Making a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached.
fJ Yes
4b. Stream mitigation requested:
(linear feet)
48
4c. If using stream mitigation, stream temperature:
warm
4d. Buffer mitigation requested (DWR only):
(squarefeet)
0
4e. Riparian wetland mitigation requested:
(acres)
0
4f. Non-riparian wetland mitigation requested:
(acres)
0
4g. Coastal (tidal) wetland mitigation requested:

(acres)
0
4h. Comments
Mitigation requested at 2:1 ratio.
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
1a. Does this project require a Stormwater Management Plan?
r Yes l" No
1b. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
Stormwater Management Plan is attached.
1c. What is the overall percent imperviousness of this project?
50
%
1d. Who will be responsible for the review of the Stormwater Management Plan?*
r Certified Local Government r DEMLR Stormwater Review
r DWR 401 & Buffer Permitting Branch �J DWR Transportation Permitting Branch
2. Diffuse Flow Plan
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 r No
If no, explain why:
Project does not occur in Riparian Buffer River Basin.
5. DWR 401 Stormwater Review
Sa. Is the Stormwater Management Plan (including BMP Supplemental Forms and Operation and Maintenance Agreements) attached?
C' Yes C' No
Stormwater Management Plan Upload
aick the upload button or drag and drop files here to attach docurrent
7) 236 SMP.pdf 60.13K6
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?*
�' Yes l" 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
Comme nts: *
i �
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 C•' No
2c. If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
NA
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 �' No
3b. If you answered "no," provide a short narrative description.
This project is a bridge to culvert project and will not increase access to nearby properties.
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.
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 C' 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
5e. Will you cut anytrees in order to conduct the work in waters of the U.S.?*
C� Yes C' No
5f. Does this project involve bridge maintenance or removal?*
C� Yes C' No
5f(1). If yes, have you inspected the bridge for signs of bat use such as staining, guano, bats, etc.? Representative photos of signs of bat
use can be found in the NLEB SLOPES, Appendix F, pages 3-7.
C� Yes C' No
Link to the NLEB SLOPES document: http://sav�reg.usace.army.mil/NLEB/1-30-17-signed_NLEB-SLOPES&apps.pctf
If you answered "Yes" to 5f(1), did you discover any signs of bat use?*
C' Yes �' No C' Unknown
If yes, please show the location of the bridge on the permit drawings/project plans.
Gick the upload button or drag and drop files here to attach docurrent
790236 Complete Set.pdf 1.73MB
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5g. Does this project involve the construction/installation of a wind turbine(s)?"`*
C' Yes C•' No
If yes, please show the location of the wind turbine(s) on the permit drawings/project plans.
qick the upload button or drag and drop files here to attach docurrent
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5h. Does this project involve (1) blasting, and/or (2) other percussive activities that will be conducted by machines, such as
jackhammers, mechanized pile drivers, etc.?*
C•' Yes C' No
If yes to either, please provide details to include type of percussive activity, purpose, duration, and specific location of this activity on
the property.
Gick the upload button or drag and drop files here to attach docurrent
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5i. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
IField surveys on September 25, 2014 and November 12, 2014 for Schweinitz's sunflower (no species present). A
bridge survey for NLEB August 4, 2014 (no bats observed). A nest survey for bald eagle was conducted on
January 14, 2014. No eagles or eagle nests located. Project not within 0.25 of known NLEB roosting site.
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?*
This bridge replacement project takes place in Rowan 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)
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)?*
C' Yes C•' No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources? *
See attached Historic Architecture and Landscapes "No Survey Required Form" and Archeological Resources "No
Historic Places or Archaeological Sites present or Affected' form.
7c. Historic or Prehistoric Information Upload
Gick the upload button or drag and drop files here to attach docurrent
5) 790236_AR15-01-0027effects.pdf
I 6) 790236_14-11-0016_NoSurveyReq.pdf
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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
5.67M6
3.08MB
8b. If yes, explain how project meets FEMA requirements:
The project is in a FEMA Detailed Study. The Project will be an MOA Type 2B. For more information please refer
to the Culvert Survey Report

8c. What source(s) did you use to make the floodplain determination?*
FEMA FIRM Maps.
Miscellaneous attachments not previously requested.
aick the upload button or drag and drop files here to attach docurrent
Figure 3_B-236_Project Vicinity.pdf 482.04KB
9) 790236_CSR 2016_SF-790236_TOWN BRANCH SR1221_Sealed.pdf 1.99MB
Br 236 cover letter.pdf 75.54K6
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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.
Full Name:*
Amy Euliss
Signature
�� �Gl�,�'S`
Date
8/8/2017
Initial Review
Is this project a public transportation project?
C� Yes C' No
Only 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*
i 20170986
Version#�
1
Reviewing Office *
Winston-Salem Regional Office - [phone]
Select Project Reviewer*
� Dave Wanucha:eads\djwanucha