20170999 Ver 1_PCN Form Submission_20170809

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 8/9/2017 4:49:19 PM (Start Event)
Accept by Carpenter,Kristi 8/10/2017 12:07:31 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: August 14, 2017 5:00 PM
8/9/2017 4:49 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:*
Johnston
Is this a NCDOT Project?*
C� Yes �' No
(NCDOT only) T.I.P. or state project number:
W-5204D
WBS #
45334.1.4
(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.
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:
State of NC
i 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
27893
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
USA
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
W-5204D
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:*
Mcgree crossroads
1d. Driving directions*
If it is a new project and can not easily be found in a C� rrepping system Rease provide directions.
E�st 319 off I-40 onto NC 210 west 0.2 miles
2. Project Identification
2a. Property Identification Number:
(tax RN or parcel ID)
2b. Propertysize:
(in acres)
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
I map coordinates to 5 or 6 digits after the decimal place.)

� Latitude:* Longitude:*
35.51944 -78.59488
ex:34208504 -77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
Camp Branch
3b. Water Resources Classification of nearest receiving water:*
C NSW
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Neuse
River Basin 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:*
suburban with some agriculture and forestry
4b. Attach an 8 1l2 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
2017-08-09_13-47-35.pdf 1.2MB
Fle type rrust be pdF
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
Fle type rrust be pdf
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:
(interrrdtent and perennial)
60
4f. Explain the purpose of the proposed project:
increasing pavement widths and superelevations in curves in order to improve the design speed.
4g. Describe the overall project in detail, including the type of equipment to be used:
going from 11' lanes to 12' lanes with 2 foot paved shoulders and increasing superelevations Banking in curve
which is increasing toe foot print. Heavy road and culvert building equipment will be used.
4h. Please upload project drawins for the proposed project.
Gick the upload button or drag and drop files here to attach docurrent
W-5204D PERMIT.pdf 1.9MB
Fle type rrust be pdf
5. Jurisdictional Determinations
Sa. Have the wetlands or streams been delineated on the propertyor proposed impact areas?*
C� Yes C' No C' Unknown

Comments:
DEO delineation
5b. 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 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Othe r:
Chad Coggins
NCDOT
Sd. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5d1. Jurisdictional determination upload
Qick the upload button or drag and drop files here to attach docurrent
Fle type rrust be FDF
6. Project History
6a. Have permits or certifications been requested or obtained for this project (including all prior phases) in the past?*
C' Yes C� No C' Unknown
7. Future Project Plans
7a. Is this a phased project?*
C' Yes �' 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 activit�/? 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 Impacts Inventory
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
r Wetlands rJ Streams-tributaries rJ Buffers
� 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.

3a. Site #- 3b.lmpact 3c. Type of 3d. Stream 3e. Stream 3f. 3g. Stream 3h. Impact
Reason for type impact name Type Jurisdiction width length
impact type
Row 1 site 1 pipe P Fill Camp Perennial Both Average 25
extension F2rrrenent (P) or Branch F2rennia� (� or � p (�inear feet)
N�p label (e.g. Terrporary (� interrrittent (IN� (feet)
Road Q'ossing 1)
Row 2 site 1 P Bank Camp
N�p label (e.g. F�rrranent (F'� or Stabilizatio BranCh
RDad Qossing 1) Terrporary (� n
Row 3 site 1 T Dewatering Camp
N�p label (e.g. F�rrranent (P� or BrBnCh
I�ad Q'ossing 1) Terrporary (�
Perennial Both
F2rennial (Fff� or
interrrittent (IfV�
Perennial Both
F�rennial (� or
interrrittent (IfVn
"" 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:
33
3i. Total temporarystream impacts:
15
3i. Total stream and tributary impacts:
48
3j. Comments:
Average
10
(feet)
Average
10
(feet)
8
(linear feet)
15
(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.
6a. Project is in which protect basin(s)?*
Check all that apply.
fJ Neuse
r Catawba
r Goose Creek
r Other
6b. Impact Type
r Tar-Pamlico
r Randleman
r Jordan Lake
6c. Per or 6d. Stream name
Te mp
Site 1 P Camp Branch
Location and Exerrpt, Allowable, allowable w/ rritigation F�rrranent (�) or
Terrporary (�
6h. Total buffer impacts:
6e. Buffer 6f. Zone 1 6g. Zone 2
mitigation impact impact
required?
No 3,066 1,922
(squarefeet) (squarefeet)

Zone 1 Zone 2
Temporary impacts: 0.00 0.00
Zone 1 Zone 2
I Permanent impacts: 3,066.00 1,922.00
Zone 1 Zone 2
Total buffer impacts: 3,066.00 1,922.00
6i. Comments:
Supporting Documentation - i.e. Impact Maps, Plan Sheet, etc.
qick the upload button a- drag and drop files here to attach docurrent
Fle rrust be FDF
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:*
just extending culvert not doing a full replacement
1b. Specificallydescribe 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 M itigation, 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
1e. If this project DOES NOT require a Stormwater Management Plan, explain why:
any ditches that are touched will be shifted out and flattened to 3:1 see detail A and C on permit drawings.
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?
G Yes C' No
2b. All buffer impacts and high ground impacts require diffuse flow or other form of stormwater treatment. Include a plan that fully
documents how diffuse flow will be maintained.
If, due to site constraints, a BMP other than a level spreader is proposed, please provide a plan for stormwater treatment as outlined
in Chapter 8 of the NC Stormwater BMP Manual and attach a BMP Supplement Form

What documentation are you providing?
r Level Spreader
r Other BMP
(check all that apply)
Diffused Flow Documentation
aick the upload button or drag and drop files here to attach docurrent
W-5204D PERMIT.pdf 1.9MB
Fle lype rrust be FDF
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?*
r Yes c' 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
Comments:*
MCDC available upon request
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 qualit�i?*
C' Yes �' No
3b. If you answered "no," provide a short narrative description.
not adding capacity
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.
none generated
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
Sb. Have you checked with the USFWS concerning Endangered Species Act impacts?*

r Yes r 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
Si. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
� NCNHP review and fieldwork
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?*
not in EFH county
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? *
HEU review
7c. Historic or Prehistoric Information Upload
C7ick the upload button or drag and drop files here to attach docurrent
JohnstonNC210HPOMemo.pdf 118.77KB
AR14-06-0029NoSitesPresent.pdf 5.85M6
Fle rrust be FDF
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?*
FRIS
Miscellaneous attachments not previously requested.
aick the upload button or drag and drop files here to attach docurrent
Fle rrust be FDF
Signature
*

N7 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:*
Chad Coggins
Signature
��r���}o�r�r.�r.J
Date
8/9/2017
Initial Review
Is this project a public transportation project?
r 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?*
�' Yes
C' No
BIMS # Assigned*
20170999
Version#*
Reviewing Office *
Central Office - [phone]
Select Project Reviewer*
Rob Ridings:eads\rgridings