20171211 Ver 1_PCN Form Submission_20170925

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 9/25/2017 2:36:15 PM (Start Event)
Accept by Carpenter,Kristi 9/25/2017 2:48:26 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: September 28, 2017 5:00 PM
9/25/2017 2:37 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:*
Cleveland
Is this a NCDOT Project?*
C� Yes �' No
(NCDOT only) T.I.P. or state project number:
B-5392
WBS #
176P.12.R.68
(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.
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?
*
C•' Yes !" 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?*
Trish Beam
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:
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:
(xxx)xxx-xxxx
2f. Fax Number:
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
3. Applicant Information (if different from owner)
3a. Applicant is:
C' Agent
C� Other
If other please specify.
3b. Name:
Mark Stafford
3c. Business Name:
State / Rovince / F�gion
Country

(if applicable)
NCDOT, Division 12
3d.Address
Street Address
1710 East Marion Street
Address Line 2
��
Shelby
Fbstal / Zip Code
28151
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
United States
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Bridge #201 Replacement, SR 1641 (Bracket Road), Cleveland County
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:*
Lawndale
1d. Driving directions*
If it is a new project and can not easily be found in a C� rrepping system Rease provide directions.
I North on Casar Lawndale Road from the town of Lawndale. Right on Bracket Road.
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:*
35.448374 -81.569467
ex:34208504 -77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
Knob Creek
3b. Water Resources Classification of nearest receiving water:*
WS-IV
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Broad
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:*
I Existing 4 span timber deck bridge on timber I beams on paved secondary road; Land use in the vicinity is
designated cropland and pasture.
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)
qick the upload button or drag and drop files here to attach docurrent
TOPO.pdf
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4.74MB
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)
Gick the upload button or drag and drop files here to attach docurrent
Soil_Map.pdf
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)
100
368.7KB
4f. Explain the purpose of the proposed project:
The purpose of the proposed work is to replace the deteriorating bridge for the safety of the travelling public.
4g. Describe the overall project in detail, including the type of equipment to be used:
Replace a deteriorating bridge on SR 1641 (Bracket Road) in Cleveland County. NCDOT proposes to replace the
epsting 4-span (2@ 40', 2@ 40'3"), timber deck bridge on timber I-beams with a 3-span (1 @ 55', 1@ 70', 1@ 35')
precast concrete bridge. Thirty four feet of permanent bank stabilization impacts at end of ditchline and in eroding
area adjacent to bridge is proposed. A total of ten feet of temporary impacts anticipated at each end of the
permanent impact area. All Best Management Practices will be utilized during the course of the project. The
Project will be constructed using typical heavy equipment (trackhoe, backhoe, etc.)
4h. Please upload project drawins for the proposed project.
C7ick the upload button or drag and drop files here to attach docurrent
B-5392 Draft Permit Drawings.pdf 1.57M6
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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:
PDEA-Raleigh office
5b. If the Corps made a jurisdictional determination, what type of determination was made? *
C' Preliminary l" Approved r Unknown
Corps AID Number:
Exarrple: SAV�2017-99999
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Other
Sandy Smith
Axiom
See attached NRTR
5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5d1. Jurisdictional determination upload
aick the upload button or drag and drop files here to attach docurrent
B5392 NRTR.pdf 3.78M6
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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 �' 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 Impacts Inventory
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
r 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.

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 1(From P Bank Knob Perennial Both Average 21
16+31 to F2rrranent(F'�or Stabilizatio Creek F�rennial(Fff�or g (linearfeet)
7 6+43 -L- Terrporary (� n interrrittent (IfV� (feet)
I�p label (e.g.
Finad Qossing 1)
Row 2
Row 3
Row 4
1 (From P Bank Knob
16+65to F�rrranern(P�or Stabilizatio Creek
16+78 -L- Terrporary (� n
fv�p label (e.g.
F�ad Qossing 1)
1 (From T Bank Knob
16+31 to �rrrenent(�jor Stabilizatio Creek
16+43 -L- Terrporary (� n
N�p label (e.g.
RDad Qossing 1)
7 (From T Bank Knob
16+65to F2rrranent(Fjor Stabilizatio Creek
16+7$ Terrporary (� n
N�p label (e.g.
13�ad Q'ossing 1)
Perennial Both average
F�rennial (� or $
interrrittent (IfV�
(feet)
Perennial Both Average
F2rennial (FH�) or $
interrrittent (IN�
(feet)
Perennial Both Average
F2rennial (FS�) or $
interrrittent (IN�
(feet)
** 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:
34
3i. Total temporary stream impacts:
10
3i. Total stream and tributary impacts:
44
3j. Comments:
13
(linear feet)
7
(linear feet)
3
(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:*
Storm water impacts to the stream have been minimized by utilizing grated inlets and pipes to collect bridge
stormwater to a Lateral 'V' Ditch with Class B Rip Rap. Rip rap at embankment will be installed to dissipate energy
to provide a non-erosive outlet velocity to the stream. The proposed rock plating in all four quadrants allov�d
1.5:1 slopes to be incorporated, minimizing fill within the creek. At the remaining three quadrants, there are no
proposed roadside ditches with concentrated flows. Due to the nature of low impact bridge replacement, the
increases in stormwater discharges (post vs pre condition) are insignificant and the existing ditches do not need to
be modified.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
NA
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
1b. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
See Attached Stormwater management plan contained within the project plans
1c. What is the overall percent imperviousness of this project?
%
1d. Who will be responsible for the review of the Stormwater Management Plan?*
� Certified Local Government
r7 DWR 401 & Buffer Permitting Branch
2. Diffuse Flow Plan
r DEMLR Stormwater Review
r 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
If no, explain why:
r No
5. DWR 401 Stormwater Review
5a. Is the Stormwater Management Plan (including BMP Supplemental Forms and Operation and Maintenance Agreements) attached?
�' Yes
l" No
Stormwater Management Plan Upload
C7ick the upload button or drag and drop files here to attach docurrent
B-5392 Draft Permit Drawings.pdf
file type rrust be pdf
G. Supplementary Information
1.57M6

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 C•' No
Comments:*
The 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 has been completed for the bridge replacement 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 �' 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 qualit�i?*
C' Yes �' No
3b. If you answered "no," provide a short narrative description.
No wastewater is generated from the project.
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?*
�' Yes �' No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
C� Yes C' No
Sc. 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
r No
5e. Will you cut anytrees in order to conduct the work in waters of the U.S.?*
�' Yes C' No

5f. Does this project involve bridge maintenance or removal?*
C' Yes C' No
Sf(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.pdf
If you answered "Yes" to 5f(1), did you discover any signs of bat use?*
C' Yes r No C' Unknown
If 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
65392 Bat Memo 2016.pdf
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139.82KB
5g. Does this project involve the construction/installation of a wind turbine(s)?**
C' Yes r 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
Fle rrust be FDF
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 G 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.
qick 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?*
I NC Natural Heritage Database and on-site surveys. Division 12 is located in the white nose syndrome area for
NLEB; however, there are no known hibernacula or roosting trees in Division 12 counties.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
C' Yes �' No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
I There are no salt marshes, oyster 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 history and 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
13-03-0071 Update_NoSurveyReq.pdf 3.85MB
No Archaeological Survey Required PA 13-03-0071.pdf 2.26M6
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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?*
�' Yes �' 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?*
Flood map, http://fris.nc.gov/fris
Miscellaneous attachments not previously requested.
Qick the upload button or drag and drop files here to attach docurrent
Flood.pdf 366.15KB
Farmland_Classification.pdf 375.59KB
Downstream_photo.pdf 107.54KB
upstream_photo.pdf 103.62KB
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Signature
*
rJ 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
F "�
_ tr�I� a��:rls�'
Date
9/25/2017
Initial Review
Is this project a public transportation project?
C•' Yes C' No
Q�ly 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
i BIMS#Assigned*
20171211
Version#*
Reviewing Office *
Mooresville Regional Office - [phone]
Select Project Reviewer*
Donna Hood:eads\drhood