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Pre-Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
June 28, 2017 Ver 1.8
*
P/ease 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 ansv�red.
Below is a link to the DRAFT online help file.
http://edocs. deq. nc.gov/WaterResources/0/doc/549884/Page 1. aspx
A. Processing Irrformation
County (or Counties) where the project is located:*
Hyde
Is this project a public transportation project?*
C•' Yes C' No
Is this a NCDOT Project?*
l•' Yes l' No
(NCDOTonly) T.I.P. or state project number:
WBS #
1.2048111
(for f�DOT use only)
1a. Type(s) of approval sought from the Corps:*
�J 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?*
�J Nationwide Permit (NWP)
� Regional General Permit (RGP)
Nationwide Permit (NWP) Number
NWP Number Other:
List all MN nurrbers you are applying for not on the drop down list.
03 - Maintenance
1c. Type(s) of approval sought from the DWR:*
check all that apply
rJ 401 Water Quality Certification - Regular
� Non-404 Jurisdictional General Permit
r 401 Water Quality Certification - Express
r Riparian Buffer Authori�ation

*
1d. Is this notification solelyfor the record because
written approval is not required?
For the record only for DWR 401 Certification: C•' Yes !" No
For the record onlyfor Corps Permit: l' Yes �' No
1e. Is payment into a mitigation bank or in-lieu fee program proposed for mitigation of impacts?
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
1g. Is the project located within a NC DCM Area of Environmental Concern (AEC)?*
!' Yes C No !' Unknown
6. Applicant Information
1 a. Who is the Primary Contact? *
Paul Williams
1 b. Primary Contact Email: *
[e-mail]
1 c. Primary Contact Phone: *
(xxx)xxx-xxxx
[phone]
1d. Who is applying for the permit?
r Owner rJ Applicant (other than owner) r AgenUConsultant
(Check all that apply)
2. Owner Irrformation
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 Line2
aty
Fbstal / Zip Code
2e. Telephone Number:
(xxx)xxx-xxxx
2f. Fax Number:
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
State / Rovince / F�gion
Courdry

3. Applicant Irrformation (if different from owner)
3a. Applicant is:
C' Agent
C•' Other
If other please specify.
3b. Name:
Paul Williams
3c. Business Name:
(if applicable)
NCDOT
3d.Address
Street Address
113 Airport Dr.
Address Line2
aty
Edenton
Fbstal / Zip Code
27932
3e. Telephone Number:
[phone]
(xxx)xxx-xxxx
3f. Fax Number:
[phone]
(xxx)xxx-xxxx
3g. Email Address:*
[e-mail]
State / Rovince / F�gion
NC
Courdry
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 e�asily be found in a C�5 rrapping system Rease provide directions.
On White Plains Road, approximately 0.53 miles from SR 1110 Nebraska Road.
2. Project Identification
2a. Property Identification Number:
(tac RN or parcel ID)
2b. Propertysize:

(in acres)
.25
2c. Project Address
Street Address
Address Line2
aty
Fbstal / Zip Code
2d. Site coordinates in decimal degrees
State / Rovince / F�gion
Courdry
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 how the 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: *
35.454268 -76.039155
eac: 34.2085Q� -77.796371
3. Surface Waters
3a. Name of the nearest bodyof 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)
C7ickthe upload kxatton or drag and drop files here to attach docurrerd
Topo SR 1108 White Plains Road - Hyde.pdf 1.01 MB
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)
C7ickthe upload kxatton or drag and drop files here to attach docurrerd
Soil_Map. pdf 482.52KB
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:
(irderrrflterd and perennial)
150

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:
The existing (2) 24" X40' RCP's will be removed and replaced with the proposed 36" X60' CAP. This work will be
accomplished using tracked excavator, backhoe, and dump trucks.
4h. Please upload project drawings for the proposed project.
C7ickthe upload kxatton or drag and drop files here to attach docurrerd
White Plains Road.pdf 143.2KB
Fle type rrust be pdf
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or proposed impact areas?*
l•' Yes l' No r' Unknown
Comments:
5b. If the Corps made a jurisdictional determination, what type of determination was made?*
C•' Preliminary !' Approved C' Unknown
Corps AID Number:
Ecarrple: S4V�2017-�JJJJ
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Other
Paul Williams
I�[a�Z��l
5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5d1. Jurisdictional determination upload
C7ickthe upload kxatton or drag and drop files here to attach docurrerd
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 !' Unknown
7. Future Project Plans
7a. Is this a phased project?*
l' 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 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
rJ 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.
** 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 Ditch 0.01
N�p label (e.g. F�ad C7ossing 1) F2rrranerrt (Fj or Creek (acres)
Terrporary (� ('rf applicable)
4g. Total temporaryopen 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 approbmately 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.
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 existing alignment and traffic will be detoured around the site by using an
offsite detour. This will reduce temporary impacts to open waters by not utilizng an on-site detour and keeping the
road open.
1b. Specificallydescribe 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.
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?
!' Yes
C�►:
2b. If this project DOES NOT require Compensatory Mitigation, explain why:
Impacts are below the threshold requiring mitigation.
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
1a. Does this project require a Stormwater Management Plan?
l•' Yes
Ci�►:
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?*
� Certified Local Government
� DWR 401 & Buffer Permitting Branch
2. Diffuse Flow Plan
r DEMLR Stormwater Review
�J 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:
Non-navigable manmade canal.
C�►:
5. DWR 401 Stormwater Review
5a. Is the Stormwater Management Plan (including BMP Supplemental Forms and Operation and Maintenance Agreements) attached?
l' Yes
C No
Stormwater Management Plan Upload
C7ickthe upload kxatton or drag and drop files here to attach docurrerd
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?*
l•' Yes
f No
1 b. 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)?*
f Yes
Comments: *
f• No

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)? *
l' 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 reasonablyanticipated future impacts) result in additional development, which could impact
nearby downstream water quality? *
l' Yes C No
3b. If you answered "no," provide a short narrative description.
Project replaces an existing 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.
No waste water will be generated from this 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?*
f Yes l� 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? *
l•' 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?*
!' Yes l� No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat? *
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 historyand archaeology)?*
l•' Yes l' 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
C7ickthe upload kxatton or drag and drop files here to attach docurrerd
Lake Landing Historic District.pdf 482.21 KB
Fle rrust be FC�
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 FEM�4designated 100-year floodplain?*
l•' 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.
C7ickthe upload kxatton or drag and drop files here to attach docurrerd
USACE Request Letter.pdf 49.18KB
Fle rrust be FC�
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:*
Paul Collins Williams, Jr.
Signature
Sign

Submission Completed
■ I intend to electronically sign and submit the PCN form.
Full Name: *
Paul Collins Williams, Jr.
Signature
Sign •
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https://edocs.deq.nc.gov/Forms/Form/showformsubmission/bb780fa5-2fl 7-44ce-bbd3-209... 9/28/2017