20171164 Ver 1_PCN Form Submission_20170911

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 9/11/2017 9:04:42 AM (Start Event)
Accept by Carpenter,Kristi 9/13/2017 1:03:15 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: September 14, 2017 5:00 PM
9/11/2017 9:05 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 #
33803.1.2
(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?
*
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?*
Amy Euliss
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 Division 9
2b. Deed book and page no.:
2c. Responsible party:
(for Corporations)
2d.Address
Street Address
375 Silas Creek Parkway
Address Line 2
��
Winston Salem
Fbstal / Zip Code
27127
2e. Telephone Number:
(xxx)xxx-xxxx
[phone]
2f. Fax Number:
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
3. Applicant Information (if different from owner)
3a. Applicant is:
�' Agent
C' Other
If other please specify.
3b. Name:
State / R-ovince / F�gion
NC
Country

3c. Business Name:
(if applicable)
3d.Address
Street Address
Address Line 2
Qty
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:*
i Replacement of Bridge No. 6 on SR 1759 (Belk Road)
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:*
Cleveland
1d. Driving directions*
IF it is a new project and can not easily be found in a C�5 rrapping system Rease provide directions.
Take 801 south to Mt. Ulla, NC. Turn left on Belk Road.
2. Project Identification
2a. Propertyldentification Number:
(tac RN or parcel ID)
2b. Propertysize:
(in acres)
0.5
2c. Project Address
Street Address
Address Line 2
��
Fbstal / Zip Code
2d. Site coordinates in decimal degrees
State / FYovince / 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 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:*
35.67439 -80.725392
ex:34208504 -77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
Back Creek
3b. Water Resources Classification of nearest receiving water:*
WSII;HQW
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Yadkin-PeeDee
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:*
Rural agriculture
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)
Gick the upload button w drag and drop files here to attach docurrent
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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)
Qick 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:
(interrrittent and perennial)
123
4f. Explain the purpose of the proposed project:
I Replace existing bridge with a new 100' long bridge
4g. Describe the overall project in detail, including the type of equipment to be used:
ebsting bridge will be demoed using Best Management Practices and a new bridge will be built with standard road
and bridge building equipment
4h. Please upload project drawins for the proposed project.
C7ick the upload button or drag and drop files here to attach docurrent
B-4628_hyd_prm_wet.pdf 205K6
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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:

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
jurisdiction determination was not requested by the USACE
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Othe r:
5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5d1. Jurisdictional determination upload
IGick 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 C� No !' Unknown
7. Future Project Plans
7a. Is this a phased project?*
C' Yes r 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.
no
D. Proposed I m pacts I nventory
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
� Wetlands fJ Streams-tributaries r Buffers
� Open Waters � 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
i Row 2
Row 3
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
1 P Bank Back Creek Perennial Both ,4verage 68
N�p label (e.g. F2rrrenent (� or Stabilizatio F2rennial (� or 25 (linear feet)
Finad Q-ossing 1) Terrporary (� n interrrittent (IN� (feet)
1 P Bank Back Creek Perennial Both
N�p label (e.g. F2rrranent (F) or Stabilizatio F2rennial (� or
F�ad Qassing 1) Terrporary (� n interrrittent (IN�
1 T Dewatering Back Creek Perennial Both
N�p label (e.g. F2rrranent (P� or F2rennial (Fff� or
f3�ad Qossing 1) Terrporary (� interrrittent (IfV�
`* 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:
118
3i. Total temporarystream impacts:
5
3i. Total stream and tributary impacts:
123
3j. Comments:
Average
25
(feet)
Average
25
(feet)
50
(linear feet)
5
(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:*
I Bridge will be replaced with a new bridge
1b. Specificallydescribe measures taken to avoid or minimize the proposed impacts through construction techniques:*
The project will utilize best management practices for bridge demolition and to control erosion.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
i 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:
bank stabilization impacts do not require mitigation
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
__ __ __ _ _ ___ _ ___ _ _ _ __ .
� 1a. Does this project require a Stormwater Management Plan?
G Yes C' No
1b. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
see attached
1c. What is the overall percent imperviousness of this project?
32
%
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 rJ 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 C•' No
If no, explain why:
no buffer rules
5. DWR 401 Stormwater Review
5a. Is the Stormwater Management Plan (including BMP Supplemental Forms and Operation and Maintenance Agreements) attached?
�' Yes �' No
Stormwater Management Plan Upload
Gick the upload button or drag and drop files here to attach docurrent
B-4628 SMP Final.pdf 95.83KB
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 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 C•' No
Comments:*
environmental document not required. No significant impacts are anticipated.
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.
Cumulative impacts not anticipated for a bridge replacement project of this size.
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 na
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
Sa. Will this project occur in or near an area with federally protected species or habitat?*
C� 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
r 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
i Link to the NLEB SLOPES document: http://sav�reg.usace.arrny.mil/NLEB/1-30-17-signed_NLEB-SLOPES&apps.pdf
If you answered "Yes" to 5f(1), did you discover any signs of bat use?*
C' Yes �' No C' Unknown
IIf yes, please show the location of the bridge on the permit drawings/project plans.
C7ick the upload button or drag and drop files here to attach docurrent
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5g. Does this project involve the construction/installation of a wind turbine(s)?**
C' Yes �' No
If yes, please show the location of the wind turbine(s) on the permit drawings/project plans.

C7ick the upload button or drag and drop files here to attach docurrent
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Sh. 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.?*
G 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.
aick the upload button or drag and drop files here to attach docurrent
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Si. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
NC Natural Heritage Database
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?*
i �
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)? *
f Yes C•' No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?*
NC DOT Human Environment Unit Review
7c. Historic or Prehistoric Information Upload
qick the upload button or drag and drop files here to attach docurrent
16-06-0032NoSurveyReq.pdf 2.55MB
AR16-06-0032NoSurvey.pdf 1.55MB
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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?*
G Yes C' No
8b. If yes, explain how project meets FEMA requirements:
MOA
8c. What source(s) did you use to make the floodplain determination?*
NC One Map
Miscellaneous attachments not previously requested.
aick the upload button or drag and drop files here to attach docurrent
Cover letter Br no 6 on SR 1759.pdf 61.17KB
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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:*
Amy Euliss
Signature
�fl� [jldl �Lt�
Date
9/11 /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*
20171164
Version#*
1
Reviewing Office*
Winston-Salem Regional Office - [phone]
Select Project Reviewer*
Dave Wanucha:eads\djwanucha