20171338 Ver 1_PCN Form Submission_20171020

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 10/20/2017 1:08:38 PM (Start Event)
Accept by Carpenter,Kristi 10/20/2017 4:00:52 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: October 25, 2017 5:00 PM
10/20/2017 1:09 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:*
Forsyth
Is this a NCDOT Project?*
�' Yes �' No
(NCDOT only) T.I.P. or state project number:
B-5152
WBS #
176P.9.R.99
(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:
Nationwide Permit (NWP) Number:
Nationwide Permit (NWP) Number
NWP Number Other:
List all MNnurrbers you are applying for not on the drop down list.
13 - Bank Stabilization
23 - Categorical Exclusions
33 - Temporary Construction
1c. Type(s) of approval sought from the DWR:*
check all that apply
�7 401 Water Quality Certification - Regular
r 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: �' Yes C� No

1d. Is this notification solelyfor the record because written approval is not required?
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?
IF so, attach the acceptance letter from rritigation bank or in-lieu fee program
r Yes l" No
Acceptance Letter Attachment
Gick the upload button or drag and drop files here to attach docurrent
B-5152 Revised - STR - RW - YD 101.pdf 64.72KB
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1f. Is the project located in anyof NC's twentycoastal counties?*
C' Yes C•' No
B. Applicant Information
1a. Who is the Primary Contact?*
NCDOT
1b. Primary Contact Email:*
[e-mail]
1c. PrimaryContact Phone:*
(xxx)xxx-xxxx
[phone]
1d. Who is applying for the permit?
�J Owner r Applicant (other than owner) r Agent/Consultant
(Check all that apply)
i 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
Qty
Fbstal / Zip Code
2e. Telephone Number:
(xxx)xxx-xxxx
2f. Fax Number:
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
State / FYovince / F�gion
Country
C. Project Information and Prior Project History
*
C' Yes C•' No

1. Project Information
1a. Name of project:*
Relacement of Bridge No. 95 on SR 1100 (Lasater Road) over Blanket
Creek.
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:*
Clemmons
I 1d. Driving directions*
IF it is a new project and can not easily be found in a C�5 rrepping system Rease provide directions.
I-40 ebt #182 (Harper Road) north, left on Fair Oaks Drive, left on Lasater Road.
2. Project Identification
2a. Property Identification Number:
(tac RN or parcel ID)
2b. Propertysize:
(in acres)
2c. Project Address
Street Address
Address Line 2
aty
Wstal / Zip Code
SYate / Rovince / F�gion
Cauntry
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
map coordinates to 5 or 6 digits after the decimal place.)
Latitude:*
36.025545
ex:34.208504
3. Surface Waters
Longitude:*
-80.419677
-77.796371
3a. Name of the nearest body of water to proposed project:*
Blanket Creek
3b. Water Resources Classification of nearest receiving water:*
WS-IV
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Yadkin-PeeDee
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:*
The project is located within the municipal limits of trhe Village of Clemmons. Development in the area is residential
in nature.
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 or 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
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4d. List the total estimated acreage of all existing wetlands on the property:
0.28
4e. List the total estimated linear feet of all existing streams on the property:
(interrrittent and perennial)
1.194
4f. Explain the purpose of the proposed project:
Bridge No. 95 has a sufficiency rating of 26.27 out of a possible 100 for a new structure. Classified as a fracture
critical structure, the bridge would collapse withthe loss of a single member. The bridge is considered structurally
deficient due to a superstructure condition of 4 out of 9 and a subsructure condition of 4 out of 9 according to
FHWA.
4g. Describe the overall project in detail, including the type of equipment to be used:
The e�asting bridge, at a stone waterfall (Lasater Mill Dam), will be abandoned, as the substructure appears to
share a foundation with the adjacent house and spillway. A new 137-foot long bridge (and new roadway) will be
relocated further downstream on Blanket Creek. Standard road building equipment, such as trucks, dozers, and
cranes will be used.
4h. Please upload project drawins for the proposed project.
C7ick the upload button or drag and drop files here to attach docurrent
65152_Permit_UTIL_RDWY.pdf 9.26MB
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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:
Initial JD in 2009; updated PJD in 2016
5b. If the Corps made a jurisdictional determination, what type of determination was made? *
�' Preliminary �' Approved f Unknown
Corps AID Number:
6carrple: SAV�2017-99999
SAW-2009-01741
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Othe r:
John Jamison
HDR Engineering

5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
November 22, 2016.
5d1. Jurisdictional determination upload
aick the upload button or drag and drop files here to attach docurrent
B-5152 PJD 11-28-2016 .pdf
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6. Project History
G'3iL�1�7:/:3
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 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
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
impact
1 - Excavation
fv�p label (e.g. Id�ad Q�ossing 1)
1 - Fill
N�p label (e.g. f�ad Qossing 1)
2 - Fill
N�p label (e.g. Fd�ad Qossing 1)
2b. Impact type * 2c. Type of wetland
P Headwater Forest
F2rrranent (� or Terrporary
��
P Headwater Forest
F�rrranent (P� or Terrporary
i�
P Bottomland Hardwood
F2rrranent (P� or Terrporary Forest
��
2d. Wetland name 2e. Forested 2f. 2g. Impact
Jurisdiction area
type
WA Yes Corps 0.020
(404, 10) or C7JVR (acres)
(401, other)
WA Yes Corps 0.040
(404, 10) or CANR (acres)
(401, other)
WC Yes Corps 0.040
(404, 10) or d�NR (acres)
(401, other)
2g. Temporary Wetland Impact
0.000
2g. Permanent Wetland Impact
0.100
2g. Total Wetland Impact
0.100
2h. Comments:
PJD Site verification determined 1:1 mitigation ratio for impacts to Wetlands WA and WC.

� 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 2- road P Culvert SC Perennial Both Average 88
Crossing F2rrranent (P� or F�rennial (Fff� or 3 (linear feet)
I�p label (e.g. Terrporary (� interrrittent (IfV� feet
� )
F�ad Qossing 1)
Row 2 2- road T Culvert SC Perennial Both average 11
crossing F2rrrenent (P) or F2rennial (�) or 3 (linear feet)
N�p label (e.g. Terrporary (� interrrittent (IN� (feet)
Raad Q'ossing 1)
Row 3 2- road P Bank SC Perennial Both Average 26
Crossing F2rrranent (P� or Stabilizatio F2rennial (� or 3 (linearfeet)
N�p label (e.g. Terrporary (� n interrrittent (If� (feet)
Fd�ad Qossing 1)
Row 4 3- bridge T Other Blanket Ck Perennial Both Average 186
N�p label (e.g. F�rrrenent (P) or F2rennial (�) or 20 (linear feet)
Road Q'ossing 1) Terrporary (� interrrittent (IN� (feet)
Row 5 3- bridge P Bank Blanket Ck Perennial Both Average 46
fv�p label (e.g. F2rrrenent (F'� or Stabilizatio F2rennial (�) or 20 (linear feet)
Finad Qossing 1) Terrporary (� n interrrittent (IN� (feet)
Row 6 4- pipe P Fill SA Perennial Both Average 90
N�p label (e.g. F2rrranent (P� or F2rennial (FB� or 2 (linear feet)
Fd�ad Q-ossing 1) Terrporary (� interrrittent (IN� (feet)
Row 7 4- pipe T Other SA Perennial Both Average 27
N�p label (e.g. F2rrranent (P� or F2rennial (Fff� or 2 (linear feet)
RDad Qossing 1) Terrporary (� interrrittent (IfV� (feet)
Row 8 Utility- T Excavation Blanket Ck Perennial Both average 3
Sewe r I�rrranent (P) or F�rennial (� or 20 (linear feet)
N�p label (e.g. Terrporary (� interrrittent (IfVn (feet)
Id�ad 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:
250
3i. Total temporary stream impacts:
227
3i. Total stream and tributary impacts:
477
3j. Comments:
PJD Site verification determined 1:1 mitigation ratio for impacts to Streams SA and SC.
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:*
The bridge spans Blanket Creek, and the bridge runoff is routed to a proposed storm drain system that outlets to
a riprap-lined ditch prior to entering UT to Blanket Creek. Grass swale treatment provided to ma�mum extent
practicable. Vegetated conveyance used where Grass Swale treatment was not met. Bank stabilization is provided
at interior bent #1 to protect the outside side slopes of Blanket Creek.
1b. Specificallydescribe measures taken to avoid or minimize the proposed impacts through construction techniques:*
Best Management Practices for Surface Waters will be used during all phases of construction.
, 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
2c. If yes, mitigation is required by (check all that apply):
r DWR �J Corps
2d. If yes, which mitigation option(s) will be used for this project?
r Mitigation bank rJ Payment to in-lieu fee program r Permittee Responsible Mitigation
4. Complete if Making a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached.
fJ Yes
4b. Stream mitigation requested:
(linear feet)
178
4c. If using stream mitigation, stream temperature:
warm
4d. Buffer mitigation requested (DWR only):
(square feet)
4e. Riparian wetland mitigation requested:
(acres)
0.10
4f. Non-riparian wetland mitigation requested:
(acres)
4g. Coastal (tidal) wetland mitigation requested:
(acres)
4h. Comments

NCDOT will mitigate for the 0.10 acre of permanent wetland impacts, and for 178 linear feet of permanent stream
impacts. The permanent wetland impacts (Wetlands WA and WC and permanent stream impacts (Streams SA and
SC) require 1:1 mitigation, per the 2016 PJD site verification visit.
NCDOT does not propose mitigation for the72 linear feet of bank stabilization impact, as it does not require fill in
the stream bed and therefore, under Section 404 of the Clean Water Act, does not constitute Loss of Waters of
the U.S. and is not subject to compensatory mitigation. Furthermore, the proposed bank stabilization is necessary
to prevent erosion and sedimentation by preventing bank de-stabilization and thereby minimiang impacts to the
environment.
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
1a. Does this project require a Stormwater Management Plan?
C� Yes
l" No
1b. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
See attached Permit Drawings
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 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:
�' No
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
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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
1c. If you answered "yes" to the above, has the document review been finalized by the State Clearing House? (If so, attach a copy of the
NEPAor SEPAfinal approval letter.)*
�' Yes C' No
NEPA or SEPA Final Approval Letter

C7ick the upload button or drag and drop files here to attach docurrent
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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 �' 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?*
f Yes C•' No
3b. If you answered "no," provide a short narrative description.
Due to the minimal transportation impact resulting from this bridge replacement, this project will neither influence
nearby land uses nor stimulate growth. Therefore, a detailed indirect or cumulative effects study will not be
necessary.
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?*
C� 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
Sd. Is this a DOT project located within Division's 1-8?*
C' Yes
C� 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?*
f 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(7), did you discover any signs of bat use?*

f Yes C' No �' Unknown
If yes, please show the location of the bridge on the permit drawings/project plans.
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5g. Does this project involve the construction/installation of a wind turbine(s)?"`*
f Yes C•' No
If yes, please show the location of the wind turbine(s) on the permit drawings/project plans.
qick the upload button or drag and drop files here to attach docurrent
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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 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.
Gick the upload button or drag and drop files here to attach docurrent
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5i. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
USFWS and NHP website were used.
A Memo, dated March 17, 2016, was submitted to USFWS-Asheville on January 30, 2017, when this project was
still federally funded, regarding the northern long-eared bat (NLEB), noting that NCDOT has determined that the
proposed action does not require separate consultation on the grounds that the proposed action is consistent with
the final Section 4(d) rule, codified at 50 C.F.R. 17.40(0) and effective February 16, 2016.
Regarding 5f and 5f1., the e�asting bridge, at a stone waterfall (Lasater Mill Dam), will be abandoned, rather than
removed, as the substructure appears to share a foundation with the adjacent house and spillway.
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 f�USEPA Documentation
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)?*
C' Yes C•' No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources? *
f�llSEPA Documentation
7c. Historic or Prehistoric Information Upload
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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?*

r Yes r No
8b. If yes, explain how project meets FEMA requirements:
i NCDOT Hydraulics Unit coordination with FEMA
8c. What source(s) did you use to make the floodplain determination?*
FEMA Maps
Miscellaneous attachments not previously requested.
aick the upload button or drag and drop files here to attach docurrent
B-5152 NLEB email_Memo.pdf 190KB
B-5152 Permit App CL.pdf 29.16K6
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Signature
*
r7 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:*
Colin Mellor
Signature
Col� �i�llor
i Date
10/20/2017
Initial Review
Is this project a public transportation project?
�' 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?*
�' Yes
C' No
BIMS # Assigned*
20171338
Version#*
1
Reviewing Office *
Winston-Salem Regional Office - [phone]
i Select Project Reviewer*
Dave Wanucha:eads\djwanucha