20171315 Ver 1_PCN Form Submission_20171018

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 10/18/2017 8:44:40 AM (Start Event)
Accept by Carpenter,Kristi 10/18/2017 3:12:55 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: October 23, 2017 5:00 PM
10/18/2017 8:45 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:*
Guilford
Is this a NCDOT Project?*
C� Yes �' No
(NCDOT only) T.I.P. or state project number:
B-4958
WBS #
40150.1.1
(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
�7 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?*
� Mr. Jerry Parker
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:
NC Department of Transportation
2b. Deed book and page no.:
2c. Responsible party:
(for Corporations)
Division Engineer NC DOT Division 7, Mr. Mike Mills, PE
2d.Address
Street Address
PO Box14996
Address Line 2
��
Greensboro
Fbstal / Zip Code
27415
2e. Telephone Number:
(xxx)xxx-xxxx
[phone]
2f. Fax Number:
[phone]
(xxx)xxx-xxxx
� 2g. Email Address:*
[e-mail]
3. Applicant Information (if different from owner)
3a. Applicant is:
C' Agent
�' Other )ivision Engineer NC DOT Division 7, Mr. Mike Mills, PE
IF other please specify.
State / FYovince / F�gion
NC
Country
USA

3b. Name:
Mr. Jerry Parker
3c. Business Name:
(if applicable)
NC Department of Transportation
3d.Address
Street Address
PO Box14996
Address Line 2
Qty
Greensboro
F�stal / Zip Code
27415
3e. Telephone Number:
[phone]
(xxx)xxx-xxxx
3f. Fax Number:
[phone]
(xxx)x�c-�oc
3g. Email Address:*
[e-mail]
State / FYovince / F�gion
NC
Country
USA
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Bridge No. 106 over Reedy Fork Creek on SR 2128 (Bunch Road)
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:*
Summerfield
1d. Driving directions*
If it is a new project and can not easily be found in a G� rrapping system Rease provide directions.
Follow I-40 W to NC-68 N in Greensboro. Use the right 3 lanes to take e�at 131 for I-40 W/Interstate 85 BUSINESS S toward U.S
70/Greensboro/Winston-Salem. Keep left to continue on I-40 W/I-856L S. Keep right at the fork to continue on I-40 W, follow signs for
Interstate 40 W/US 220 S/Winston - Salem. Take exit 210 from I-40 W. Turn right onto NC-68 N(signs for Airport). Turn right onto Edgefield
Rd. Turn left onto Alcorn Rd. Turn right onto NW School Rd. Turn right onto Bunch Rd. Arrive at Project Site in 0.5 miles.
2. Project Identification
2a. Property Identification Number:
(t�vc RN or parcel ID)
f�UA Bridge Replacement
2b. Propertysize:
(in acres)
N/A Bridge Replacement
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:�
36.172887 -79.953126
ex:34208504 -77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
Reedy Fork Creek
3b. Water Resources Classification of nearest receiving water:*
16-11-(1); WS-II; NSW; 03030002; 03-06-02
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Cape Fear
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:*
I The project study area is comprised of existing maintained right of way, pasture, forested land and residential.
There is also a utility powerline corridor through the project.
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
106_USGS_Map.pdf 9.54MB
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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)
Gick the upload button or drag and drop files here to attach docurrent
106_Soil_Map.pdf 2.04M6
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4d. List the total estimated acreage of all existing wetlands on the property:
Approwmately 1.5 acres within the project study area; however there is
approwmately 1/10 acre in the project area.
4e. List the total estimated linear feet of all existing streams on the property:
(interrrittent and perennial)
Appro�mately 120 linear feet within the project study area.
4f. Explain the purpose of the proposed project:

The purpose of the project is to replace a functionally obsolete, prestressed concrete channel beams and timber
piles and end bents, triple-span bridge (91 feet total) with a new, dual-span, 100 foot long, cored slab bridge. The
bridge opening will be increased from 598 square feet to 678 square feet, reducing bridge opening velocities.
4g. Describe the overall project in detail, including the type of equipment to be used:
The proposed structure has been designed to have as little environmental and surface water impacts as possible.
Traffic will be detoured off-site. Erosion and sedimentation control measures will be installed before construction
begins. The old bridge will be removed according to the Bridge Demolition BMP manual. The proposed bridge
structure will be replaced on the e�asting alignment. The north stream bank will be armored with Class II rip-rap to
stabilize the e�asting, ongoing erosion. The e�asting ditch in the south east quadrant is unstable and actively
eroding. This ditch will be widened/improved to 3-feet and stabilized with Class I rip-rap down to Reedy Fork
Creek. Ditches in the remaining quadrants are presently vegetated and stable and these will be maintained with
the project. As the proposed replacement structure is within the same general area and location of the e�asting
bridge, the increases in stormwater discharges (pre vs post construction) are insignificant and the e�asting ditches,
with the exception of the severely eroded one, do not need to be modified. Therefore, additional stormwater
measures are not required. Equipment to be sued includes a track hoe, dump truck, possibly a crane, paving
equipment and various hand tools.
4h. Please upload project drawins for the proposed project.
C7ick the upload button or drag and drop files here to attach docurrent
B-4958_hyd_v�t_08302017.pdf
B-4958_hyd_buffer_08302017.pdf
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5. Jurisdictional Determinations
2.84M6
2.43M6
5a. Have the wetlands or streams been delineated on the propertyor proposed impact areas?*
C� Yes C' No C' Unknown
Comme nts:
5b. If the Corps made a jurisdictional determination, what type of determination was made? *
C� Preliminary �' Approved C' Unknown
Corps AID Number:
6carrple: SAV�2017-99999
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Othe r:
Robert Lepsic and Amy James
EPR
5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
On February 22, 2017, Dave Bailey (USACE) and Dave Wanucha (NCDWR) conducted onsite determinations of the drainage features to
determine applicabilty to the 404/401 permitting and the Jordan Buffer Rules. Per current NCDOT-USACE v�rork relationship, the USACE will
issue the JD with the permit approval.
5d1. Jurisdictional determination upload
Gick the upload button or drag and drop files here to attach docurrent
DWR Determinations.pdf
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6. Project History
2.25M6
6a. Have permits or certifications been requested or obtained for this project (including all prior phases) in the past?*
f Yes C•' No f" 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):
I7 Wetlands I7 Streams-tributaries N7 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.
2a. Site #- Reason for 2b. Impact type * 2c. Type of wetland 2d. Wetland name 2e. Forested 2f. 2g. Impact
impact Jurisdiction area
type
Site 1- Temporary P Bottomland Hardwood WA Yes Both 0.010
ConstruCtion ACCess F�rrranent (P� or Terrporary Forest (404, 10) or Cl,�R (acres)
N�p label (e.g. F�ad Qassing 1) �� (401, other)
2g. Temporary Wetland Impact
0.000
2g. Permanent Wetland Impact
0.010
2g. Total Wetland Impact
0.010
2h. Comments:
Please note that actually less than 0.10 acres of wetland will be cleared via mechanized clearing for construction
access to this project site.
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 Site 1- P Stabilizatio Reedy Fork Perennial Both Average 20
Embankme F2rrranent(Fjor n CPeek F2rennial(FB�or 3 (linearfeet)
nt Rip Rap Terrporary (� interrrittent (IN� (feet)
16+70 LT/RT
N�p label (e.g.
Fd�ad Qossing 1)

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 2 Site 1- T Stabilizatio Reedy Fork Perennial Both Average 40
Empankme F2rrranent (� or n Creek F2rennial (� or g (linearfeet)
I rlt Rip Rep Terrporary (� interrrittent (IN� (feet)
N�p label (e.g.
RDad Q'ossing 1)
Row 3 Bank P Bank Reedy Fork Perennial Both Average 100
Stablllzatio F2rrranent (F) or Stabilizatio CPeek F2rennial (FB� or 3 (linearfeet)
n 16+25 Terrporary (� n interrrittent (IN�
(feet)
LT/RT
N�p label (e.g.
F3�ad Qossing 1)
Row 4 Bank T Stabilizatio Reedy Fork Perennial Both Average 20
Stabillzatlo F2rrranent(F'jor n CPeek F2rennial(FB�or 3 (linearfeet)
n 16+25 Terrporary (� interrrittent (IN� (feet)
� LT/RT
N�p label (e.g.
RDad Qossing 1)
�` 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:
120
3i. Total temporary stream impacts:
60
3i. Total stream and tributary impacts:
180
3j. Comments:
Please note that the permanent stream impacts are associated with stream bank and embankment stabilization; in
other words, the thalweg of the channel is not permanently impacted due to this project.
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.
6a. Project is in which protect basin(s)?*
Check all that apply.
r Neuse r Tar-Pamlico
r Catawba r Randleman
r Goose Creek �J Jordan Lake
r Other

6b. Impact Type
6c. Per or 6d. Stream name
Te mp
Site 1- Embankment/Access 15+00 P Reedy Fork Creek
to 17+40 L- LT/RT F�rrranent (Fj or
Location and 6cerrpt, Allowable, allowable w/ rritigation Terrporary (�
Bridge 16+04 to 17+04 -L- P Reedy Fork Creek
Location and C errpt, Allowable, allowable w/ rritigation F2rrranent (P) or
Terrporary (�
6h. Total buffer impacts:
Temporary impacts:
Permanent impacts:
Total buffer impacts
6i. Comments:
Zone 1
0.00
Zone 1
4,752.00
Zone 1
4,752.00
Supporting Documentation - i.e. Impact Maps, Plan Sheet, etc.
C7ick the upload button or drag and drop files here to attach docurrent
B-4958_hyd_wet_08302017.pdf
B-4958_hyd_buffer_08302017.pdf
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Zone 2
0.00
Zone 2
2,742.00
Zone 2
2,742.00
E. Impact Justification and Mitigation
� 1. Avoidance and Minimization
6e. Buffer
mitigation
required?
No
No
2.84MB
2.43M6
6f. Zone 1 6g. Zone 2
impact impact
1,973 2,354
(square feet) (square feet)
2,779 388
(squarefeet) (squarefeet)
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:*
i NCDOT is replacing a functionally obsolete bridge with a new, longer bridge structure. The proposed structure has
been designed to have as little environmental and surface water impacts as possible. Traffic will be detoured off-
site. Erosion and sedimentation control measures will be installed before construction begins. The old bridge will
be removed according to the Bridge Demolition BMP manual. The proposed bridge structure will be replaced on
I the existing alignment. The north stream bank will be armored with Class II rip-rap to stabilize the ebsting, ongoing
erosion. The e�sting ditch in the south east quadrant is unstable and actively eroding. This ditch will be
widened/improved to 3-feet and stabilized with Class I rip-rap down to Reedy Fork Creek. Ditches in the remaining
quadrants are presently vegetated and stable and these will be maintained with the project. As the proposed
replacement structure is within the same general area and location of the existing bridge, the increases in
stormwater discharges (pre vs post construction) are insignificant and the existing ditches, with the exception of
I the severely eroded one, do not need to be modified. Therefore, additional stormwater measures are not required.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
Erosion and sedimentation BMPs will be installed prior to construction. Impacts will be minimized by strict
enforcement of Best Management Practices for the protection of surtace waters, restrictions against the staging of
equipment in or adjacent to waters of the US and coordination (including a pre-construction meeting) with the
i Division Environmental Supervisor.
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 �' No
2b. If this project DOES NOT require Compensatory Mitigation, explain why:
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
1a. Does this project require a Stormwater Management Plan?
f Yes C•' No
1e. If this project DOES NOT require a Stormwater Management Plan, explain why:
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
2b. All buffer impacts and high ground impacts require diffuse flow or other form of stormwater treatment. Include a plan that fully
documents how diffuse flow will be maintained.
If, due to site constraints, a BMP other than a level spreader is proposed, please provide a plan for stormwater treatment as outlined
in Chapter 8 of the NC Stormwater BMP Manual and attach a BMP Supplement Form
What documentation are you providing?
r Level Spreader
r7 Other BMP
(check all that apply)
Diffused Flow Documentation
C7ick the upload button or drag and drop files here to attach docurrent
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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 �' 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:*
While this project involves the expenditure of public funds, it falls below the thresholds of NEPA/SEPA
documentation.
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.
Per the NC DWQ April 10, 2004 Version 2.1 Cumulative Impacts policy, small scale public transportation projects —
such as widening projects, bridge replacements and intersection improvements — have a"low potential for
cumulative impact since little (if any) new impervious surface is added and the projects are usually in already
developed locales." This proposed project is within a somewhat developed landscape (i.e. e�sting residential
homes in the vicinity), this is not a road on a new location (i.e. there is an e�sting road and bridge structure and
thus, the area already contains impervious surfaces) and the project drains to Reedy Fork Creek wt�ich is Class
WS-III; Nutrient Sensitive Waters (NSW) (i.e. not HQW, ORW or 303(d) listed waters). We anticipate the NC DWR
will advise us if a qualitative or quantitative analysis is needed.
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.
It is not anticipated that this project will generate any wastewater as it is a roadway 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? *
C' 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.
Raleigh
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?*
The only listed species in the project area is the Small whorled Pogonia. During the field reconnaissance it was
determined there was no habitat present for the listed species.
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?*
This bridge replacement project takes place in Guilford County which is not near any coastal or tidal habitat that
would support EFH (i.e. salt marshes, oyster reefs, etc.).
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? *
NCDOT's Human Environment Unit reviewed the project for Historic Architecture and for Archaeological resources
in January 2016. They determined no surveys v�re required.
7c. Historic or Prehistoric Information Upload
C7ick the upload button or drag and drop files here to attach docurrent
B-4958 Archaeological NO Survey Required Form.pdf 1.6MB
B-4958_Architectural NO Survey .pdf 3.8MB
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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 l" No
8b. If yes, explain how project meets FEMA requirements:
NCDOT MOA
8c. What source(s) did you use to make the floodplain determination?*
http://fris.nc.gov/fris/Index.asp�C?FIPS=081&ST=NC&user=General Public
Miscellaneous attachments not previously requested.
aick the upload button or drag and drop files here to attach docurrent
D7_T&E_Lttr.pdf 106.17KB
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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:*
J. M. Mills
Signature
�I�`J�o
��
Date
10/18/2017
Initial Review
Is this project a public transportation project?
r 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*
20171315
Version#*
Reviewing Office *
Central Office - [phone]
Select Project Reviewer*
April Norton:eads\arnorton