20171147 Ver 1_PCN Form Submission_20170908

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 9/8/2017 3:16:06 PM (Start Event)
Accept by Carpenter,Kristi 9/8/2017 3:44:29 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: September 13, 2017 5:00 PM
9/8/2017 3:16 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:*
Lincoln
Is this a NCDOT Project?*
C� Yes �' No
(NCDOT only) T.I.P. or state project number:
WBS #
176P.12.R.19
(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 1199 - Bridge 127 - Division 12 - STR - CT 02 (warm).pdf 62.41 KB
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?*
Trish Beam
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
2b. Deed book and page no.:
2c. Responsible party:
(for Corporations)
2d.Address
Street Address
PO Box 47
Address Line 2
��
Shelby
Fbstal / Zip Code
28151
2e. Telephone Number:
(xxx)x�c-�oc
[phone]
2f. Fax Number:
[phone]
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
3. Applicant Information (if different from owner)
State / R-ovince / F�gion
North Carolina
Country
US

3a. Applicant is:
C' Agent
C' Other
If other please specify.
3b. Name:
3c. Business Name:
(if applicable)
3d.Address
Street Address
Address Line 2
�'
Fbstal / Zip Code
3e. Telephone Number:
(xxx)xxx-xxxx
3f. Fax Number:
(xxx)xxx-xxxx
3g. Email Address:*
[e-mail]
State / Rovince / F�gion
Country
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Bridge #127 Replacement on SR 1199 (Trinity Church Road)
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:*
Vale
1d. Driving directions*
IF it is a new project and can not easily be found in a GPS rrapping system Rease provide directions.
https://vwwv.google.com/maps/place/Trin ity+Chu rch+Rd,+Vale,+NC+28168/@35.5463125,-
81.405525,16zJdata=!4m5!3m4!1sOx8856d3bd40364a59:Ox6538ac710552002!8m2!3d35.5527134!4d-81.404446
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
2d. Site coordinates in decimal degrees
State / R-ovince / F�gion
Country
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 e�mple, most mobile phones with GPS provide locational precision in decimal degrees to
map coordinates to 5 or 6 digits after the decimal place.)
I Latitude:* Longitude:�
35.547063 -81.402349
ex:34208504 -77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
Unnamed tributary to Howards Creek
3b. Water Resources Classification of nearest receiving water:*
Class C
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Catawba
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:*
Bridge on paved secondary road. Surrounding land use residential and open farmland
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
topo_map_from_Banoak_quad.pdf 135.57KB
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
Soil_map.pdf 330.78KB
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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)
100
4f. Explain the purpose of the proposed project:
I To replace a deteriorating bridge for the safety of the travelling public
4g. Describe the overall project in detail, including the type of equipment to be used:

State Project 17BP.12.R.19 involves the replacement of Lincoln County Bridge #127 on SR 1199 (Trinity Church
Road) over FEMA Regulated Stream Howards Creek Tributary
7. The e�sting bridge, which consists of 1@ 25' - 6" timber deck on steel I-beams on timber caps and piles, will be
replaced with double RCBC @ 15'-0" x 6'-6" on the same location.
Proposed ditches in all four quadrants will utilize 3:1 or flatter front slopes and 2:1 back slopes to replicate e�asting
conditions. To protect these new ditches from "head cutting", Class 'll" Rip Rap (Rip Rap at Embankment) will be
placed as it ties to the unnamed tributary to Howards Creek.
4h. Please upload project drawins for the proposed project.
Gick the upload button or drag and drop files here to attach docurrent
project_drawings. pdf 196.58KB
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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
Comme nts:
Jurisdictional determination made by Division 12 Environmental Office
5b. If the Corps made a jurisdictional determination, what type of determination was made? *
C' Preliminary �' Approved C' Unknown
Corps AID Number:
Exarrple: SAV�2017-99999
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Othe r:
NCDOT Environmental Office
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
i DEQ_StreamlD_form.pdf 36.34KB
USACE_JD_form.pdf 317.03KB
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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 �' 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 rJ 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.
Row 1
Row 2
Row 3
3a. Site # - 3b.lmpact
Reason for type
impact
1 P
N�p label (e.g. F�rrranent (P� or
I�ad Qossing 1) Terrporary (�
3c. Type of 3d. Stream 3e. Stream 3f. 3g. Stream 3h. Impact
impact name Type Jurisdiction width length
type
Culvert UTto Perennial Both average 48
HowBrdS �rennial (� or � � (linear feet)
Creek interrrittent(IfVn
(feet)
1 P Other UTto Perennial Both
N�p label (e.g. F�rrranent (P) or Howards F2rennial (�) or
Road Q'ossing 1) Terrporary (� Creek interrrittent (IN�
1 T Dewatering UTto Intermittent Both
N�p label (e.g. F2rrranent (� or HOWaI'ds F2rennial (�) or
F�ad C7ossing 1) Terrporary (� Creek interrrittent (IN�
*' All Perennial or Intermittent streams must be verified by DWR or delegated local government.
Average
11
(feet)
Average
11
(feet)
3i. Total jurisdictional ditch impact in square feet:
0
3i. Total permanent stream impacts:
113
3i. Total temporary stream impacts:
32
3i. Total stream and tributary impacts:
145
3j. Comments:
"Other" impacts are upstream and downstream channel improvements (i.e. floodplain benches at the inlet and
outlet of the high flow culvert cell to maintain stream dimensions).
65
(linear feet)
32
(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:*
Grassed shoulders and flattened roadway embankments are utilized throughout the project to the extent
practicable to provide passive stormwater treatment for roadway runoff.
Also, e�asting drainage patterns are maintained and vegetated ditches are proposed to promote sedimentation,
filtration and infiltration.The alignment of the proposed RCBC was set parallel to the existing stream centerline and
minimizes upstream and downstream impacts. All disturbed areas will be seeded with the appropriate seasonal
seed mixtures. Proposed upstream and downstream channel improvements will be stabilized with a combination of
Class 'll' Rip Rap and Coir Fiber Matting. While permanent site vegetation is being
established, erosion control matting will be utilized to minimize erosion. Also, erosion control matting will be utilized
on 2:1 slopes.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
The proposed RCBC will be constructed utilizing impervious dikes and a"pump and pipe" operation. Dewatering of
the construction area will be into Special Stilling Basins.
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 N7 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.
� Yes
4b. Stream mitigation requested:
(linear feet)
96
4c. If using stream mitigation, stream temperature:
warm
4d. Buffer mitigation requested (DWR only):
(squarefeet)
4e. Riparian wetland mitigation requested:
(acres)
4f. Non-riparian wetland mitigation requested:
(acres)
4g. Coastal (tidal) wetland mitigation requested:
(acres)
4h. Comments
Mitigation requested for the 48 foot long culvert at 2:1 ratio = 96 feet
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:
See attached stormwater plan for bridge replacement
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 DEMLR Stormwater Review
rJ DWR 401 & Buffer Permitting Branch r 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 �' No
If no, explain why:
5. DWR 401 Stormwater Review
5a. Is the Stormwater Management Plan (including BMP Supplemental Forms and Operation and Maintenance Agreements) attached?
C•' Yes C' No
Stormwater Management Plan Upload
qick the upload button or drag and drop files here to attach docurrent
stormwater_management_plan.pdf 208.66KB
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 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 r No
Comments:*
The proposed project is listed as a type and class of activity which qualifies as a Non-Major Action under the
Minimum Criteria rules; therefore a minimum criteria checklist was completed for the project.
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 �' No
3b. If you answered "no," provide a short narrative description.
Bridge replacement in rural area
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.
i No wastewater generated from 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?*
G Yes C' No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
�' Yes l" No
5c. If yes, indicate the USFWS Field Office you have contacted.
Asheville
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.?*
G Yes C' No
5f. Does this project involve bridge maintenance or removal?*
�' 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.
G Yes C' No
Link to the NLEB SLOPES document: http://sav�reg.usace.army.mil/NLEB/1-30-17-signed_NLEB-SLOPES&apps.pdF
If you answered "Yes" to 5f(1), did you discover anysigns of bat use?*
C' Yes C•' 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
project_drawings.pdf 196.58KB
bat_habitat_assessment.pdf 61.01 KB
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5g. Does this project involve the construction/installation of a wind turbine(s)?"`*
f 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 �' 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.
C7ick 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?*
NC Natural Heritage Program database and on-site surveys.
No impact on any federally listed threatened/endangered species. Question 5a was answered yes because the
project is located in Division 12, which is located in the white nose syndrome area. There are no known
hibernacula nor roosting trees in Division 12, so the criteria for the 4(d) rule has been met and any associated
take is exempt. A streamlined consultation form for NLEB will be completed.
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?*
There are no salt marshes, oysters reefs, or seagrass beds located in the vicinity of the project.
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 �' No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?*
Cultural Resources Review
7c. Historic or Prehistoric Information Upload
C7ick the upload button or drag and drop files here to attach docurrent
11-09-0058 Lincoln (Resubmit).pdf
11-09-0058_historic architecture.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
8b. If yes, explain how project meets FEMA requirements:
NCDOT hydraulics coordination with FEMA
8c. What source(s) did you use to make the floodplain determination?*
Consultant determined
Flood map, http://fris.nc.gov/fris
Miscellaneous attachments not previously requested.
3.89MB
520.6KB

C7ick the upload button or drag and drop files here to attach docurrent
Flood_map.pdf 345.45KB
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Signature
*
fJ 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:*
Trish Beam
Signature
T{�`I 3e�
Date
9/8/2017
� 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*
20171147
Version#*
1
Reviewing Office *
I Mooresville Regional Office -[phone]
Select Project Reviewer*
Donna Hood:eads\drhood