20171227 Ver 1_PCN Form Submission_20170928

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 9/28/2017 1:10:29 PM (Start Event)
Accept by Carpenter,Kristi 9/28/2017 4:22:01 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: October 3, 2017 5:00 PM
9/28/2017 1:11 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:*
Hyde
Is this a NCDOT Project?*
�' Yes �' No
(NCDOT only) T.I.P. or state project number:
WBS #
1.2048111
(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?
*
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 l" No
1g. Is the project located within a NC DCM Area of Environmental Concern (AEC)?*
C' Yes �' No C' Unknown
B. Applicant Information
1a. Who is the Primary Contact?*
Paul Williams
1b. Primary Contact Email:*
[e-mail]
1c. PrimaryContact Phone:*
(xxx)xxx-xxxx
[phone]
1d. Who is applying for the permit?
r Owner �J Applicant (other than owner) r Agent/Consultant
(Check all that apply)
2. Owner I nformation
2a. Name(s) on recorded deed:
NCDOT Right-of-Way SR 1108 - Hyde County
2b. Deed book and page no.:
2c. Responsible party:
(for Corporations)
2d.Address
Street Address
Address Line 2
�Y
Fbstal / 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:
�' Agent
r Other tiCDOT Division 1 Environmental Specialist
If other please specify.
3b. Name:
State / FYovince / F�gion
Country

Paul Williams
3c. Business Name:
(if applicable)
NCDOT
3d.Address
Street Address
113 Airport Dr.
Address Line 2
Qty
Edenton
Fbstal / Zip Code
27932
3e. Telephone Number:
[phone]
(xxx)xxx-xxxx
3f. Fax Number:
[phone]
(xxx)xxx-x�cx
3g. Email Address:*
[e-mail]
State / Fl-ovince / F�gion
NC
Country
USA
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
SR 1108 White Plains Road Pipe Replacement
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:*
Engelhard
1d. Driving directions*
If it is a new project and can not easily be found in a G� rrapping system Rease provide directions.
On White Plains Road, approbmately 0.53 miles from SR 1110 Nebraska Road.
2. Project Identification
2a. Property Identification Number:
(tax RN or parcel ID)
2b. Propertysize:
(in acres)
.25
2c. Project Address
Street Address
Address Line 2
�Y
Fbstal / Zip Code
State / R-ovince / F�gion
Country

2d. Site coordinates in decimal degrees
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 e>cample, 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:*
35.454268 -76.039155
ex:34.208504 -77.796371
3. SurFace Waters
3a. Name of the nearest body of water to proposed project:*
Unnamed canal to Lone Tree Creek
3b. Water Resources Classification of nearest receiving water:*
SA;HQW
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Tar-Pamlico
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:*
Project area consist of NCDOT SR 1108 and culvert in UT to Lone Tree Creek. The adjacent property use is
agricultural with rural residences in the vicinity.
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
Topo SR 1108 White Plains Road - Hyde.pdf 1.01 MB
Fle type rrust be pdF
4c. Attach an 8 1/2 X 11 ezcerpt 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
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)
150
482.52KB
4f. Explain the purpose of the proposed project:
Replace deteriorating culvert and maintain a stabile road way along SR 1108 for the safety of the traveling public.
4g. Describe the overall project in detail, including the type of equipment to be used:
i The e�sting (2) 24" X 40' RCP's will be removed and replaced with the proposed 36" X 60' CAP. This work will be
accomplished using tracked excavator, backhoe, and dump trucks.
4h. Please upload project drawins for the proposed project.

C7ick the upload button or drag and drop files here to attach docurrent
White Plains Road.pdf 143.2K6
Fle type rrust be pdF
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the propertyor proposed impact areas?*
C� Yes C' No C' Unknown
Comments:
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:
Paul Williams
NCDOT
5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
Sd1. 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 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.
D. Proposed I m pacts I nventory
1. Impacts Summary
I 1a. Where are the impacts associated with your project? (check all that apply):
r Wetlands r Streams-tributaries r Buffers
fJ 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.
"" All Perennial or Intermittent streams must be verified by DWR or delegated local government.
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.
4a. Site #- Reason for 4b. Impact 4c. Name of waterbody 4d. Activity 4e. Waterbody4f. Impact area
impact type type type
Culvert Extension P Unnamed canal to Lone Tree Culverts
N�p label (e.g. Fd�ad Q-ossing 1) F2rrranent (Pj or Creek
Terrporary (� �rf applicable)
4g. Total temporary open water Impacts:
0.00
4g. Total permanent open water impacts:
0.01
4g. Total open water impacts:
0.01
4h. Comments:
Area impacted will be approximately 142 sq. ft. of fill for culvert extension. Stream index # 29-60-5
5. Pond or Lake Construction
If pond or lake construction is proposed, then complete the chart below.
Ditch 0.01
(acres)
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:*
Culvert replacement will stay on the e�asting alignment and traffic will be detoured around the site by using an
offsite detour. This will reduce temporary impacts to open waters by not utilizing an on-site detour and keeping the
road open.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
NCDOT BMP's will be followed during bridge removal/installation and erosion control devices will be installed to
prevent sediment loss from the project site. NCDOT BMP's will be followed for the dewatering operation.
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
I 2b. If this project DOES NOT require Compensatory Mitigation, explain why:

Impacts are belowthe threshold requiring mitigation.
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:
NCDOT will follow best management practices for soil and erosion control in compliance with N.C. Sediment and
Pollution Control Act and NCDOT NPDES permit. Erosion control devices will be installed and maintained during
the project.
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
r DWR 401 & Buffer Permitting Branch �7 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:
Non-navigable manmade canal.
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
Gick the upload button or drag and drop files here to attach docurrent
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 �' No
Comments:*
Activity and impacts covered by Minimum Criteria Checklist.
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 quality?*
C' Yes �' No
3b. If you answered "no," provide a short narrative description.
i Project replaces an e�sting culvert with a culvert.
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 waste water will be generated from this project.
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
C' No
5i. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
NC Natural Heritage Data Explorer Website
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 National Marine Fisheries Database
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 C' No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources? *
State Historic Preservation Office Historic Properties Map Website

7c. Historic or Prehistoric Information Upload
C7ick the upload button or drag and drop files here to attach docurrent
Lake Landing Historic District.pdf 482.21 KB
Fle rrust be FiJF
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 l" No
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination?*
� NCFloodmaps.com, Zone AE
Miscellaneous attachments not previously requested.
aick the upload button or drag and drop files here to attach docurrent
USACE Request Letter.pdf 49.18K6
Fle rrust be FDF
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:*
Paul Collins Williams, Jr.
Signature
Sign
Date
9/28/2017
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*
20171227
Version#�

Reviewing Office *
Washington Regional Office - [phone]
Select Project Reviewer*
Garcy Ward:eads\gpward