20171369 Ver 1_PCN Form Submission_20171026

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 10/26/2017 9:34:11 PM (Start Event)
Accept by Carpenter,Kristi 10/27/2017 1:57:58 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: October 31, 2017 5:00 PM
10/26/2017 9:34 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:*
Robeson
Is this a NCDOT Project?*
C� Yes �' No
(NCDOT only) T.I.P. or state project number:
B-4620
WBS #
38438.1.2
(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:
NWP Number Other:
List all MNnurrbers you are applying for not on the drop down list.
03 - Maintenance
12 - Utility Lines
1c. Type(s) of approval sought from the DWR:*
check all that apply
fJ 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:
*
C' Yes C•' No
For the record only for Corps Permit: r Yes C' 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
B. Applicant Information
1a. Who is the Primary Contact?*
Gordon Cashin
1b. PrimaryContact Email:*
[e-mail]
1c. PrimaryContact Phone:*
(xxx)xxx-xxxx
[phone]
1d. Who is applying for the permit?
� 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
Qty
Fbstal / Zip Code
2e. Telephone Number:
(xxx)xxx-xxxx
2f. Fax Number:
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
State / Rovince / F�gion
Country
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
B-4620 Bridges 121 & 123 over Ashpole Swamp on SR 2455 (White Pond
Road)
1b. Subdivision name:

(if appropriate)
1c. Nearest municipality/town:*
Fairmont
1d. Driving directions*
If it is a new project and can not easily be found in a GPS rrapping system Rease provide directions.
Bridges 121 & 123 over Ashpole Swamp on SR 2455 (White Pond 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
�Y
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 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.)
� Latitude:*
34.447442
ex:34.208504
3. Surface Waters
Longitude:*
-79.165344
-77.796371
3a. Name of the nearest body of water to proposed project:*
Ashpole Swamp
3b. Water Resources Classification of nearest receiving water:*
C; Sw
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Lumbe r
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 Rural residential, agriculture, fragmented forestland along stream corridors and floodplains.
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
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)
Gick the upload button or drag and drop files here to attach docurrent
Fle type rrust be pdF
4d. List the total estimated acreage of all existing wetlands on the property:
7.3
4e. List the total estimated linear feet of all existing streams on the property:
(interrrittent and perennial)
479
4f. Explain the purpose of the proposed project:
i Replace Bridges 121 and 123 in Robeson County
4g. Describe the overall project in detail, including the type of equipment to be used:
I The NCDOT proposes to replace Bridges 121 and 123 on SR 2455 (White Pond Road) over Ashpole Swamp in
Robeson County, North Carolina. Standard roadway construction methods and equipment will be used. The
proposed review date is 1/30/2018, and proposed let date is 3/20/2018.
4h. Please upload project drawins for the proposed project.
C7ick the upload button or drag and drop files here to attach docurrent
B-4620 attachments.pdf 4.39M6
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:
6carrple: SAV�2017-99999
SAW-2013-00016
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Othe r:
Robert Turnbull
Environmental Services, Inc.
5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
8/6/2013
5d1. Jurisdictional determination upload
C7ick the upload button or drag and drop files here to attach docurrent
I B-4620 JD.pdf 3.13MB
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?*
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
7a. Where are the impacts associated with your project? (check all that apply):
fJ 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.
2a. Site #- Reason for 2b. Impact type * 2c. Type of wetland 2d. Wetland name 2e. Forested 2f. 2g. Impact
i impact Jurisdiction area
type
Bridge #121 P Riverine Swamp Forest Site 1
fv�p label (e.g. Id�ad Qossing 1) F2rrrenent (F) or Terrporary
��
Roadwayfill between P Riverine Swamp Forest Site 1/2
bridgeS F2rrranent (P� or Terrporary
N�p label (e.g. F�ad Qassing 1) ��
2g. Temporary Wetland Impact
0.000
2g. Permanent Wetland Impact
0.090
2g. Total Wetland Impact
0.090
Yes Both 0.010
(404, 10) or CMR (acres)
(401, other)
Yes Both 0.080
(404, 10) or [7�R (acres)
(401, other)
2h. Comments:
Bridge and roadway fill construction will involve 0.09 acre of handclearing, and there will also be 0.21 acre of
handclearing for utilities. Installation of erosion control measures will involve 0.03 acre of temporary fill in wetlands
in the hand clearing areas for the installation of erosion control measures, including temporary silt fence and/or
special sediment control fence.
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
impact
Bridge #121
N�p label (e.g. Fd�ad Q-ossing 1)
Bridge #123
N�p label (e.g. 13�ad Qossing 1)
4b. Impact 4c. Name of waterbody
type
T Ashpole Swamp
F2rrrsnent (Pj or (if applicable)
Terrporary (�
T Ashpole Swamp
F�rrranent (� or (if applicable)
Terrporary (�
4g. Total temporary open water Impacts:
0.02
4g. Total permanent open water impacts:
0.00
4g. Total open water impacts:
0.02
4h. Comments:
I impact at each site is >0.01 however 0.01 has to be entered
5. Pond or Lake Construction
If pond or lake construction is proposed, then complete the chart below.
4d. Activity 4e. Waterbody4f. Impact area
type type
Bridge Tributary 0.01
(acres)
Bridge Tributary 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:*
Replacement on ewsting alignment with an offsite detour. Rip rap pads will be used at all ditch outlets to reduce
flow into wetlands. The proposed improvements will not require deck drains. 3:1 slopes will be used in jurisdictional
areas.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
I Replacement on existing alignment with an offsite detour. BMP's for Construction and Maintenance Activities will be
adhered to.
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:
Due to minimal impacts to wetlands and surface waters no compensatory mitigation is proposed.
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
1a. Does this project require a Stormwater Management Plan?
G Yes C' 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 DEMLR Stormwater Review
r DWR 401 & Buffer Permitting Branch �J 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:
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
aick 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?*
G 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
NEPA or SEPA final approval letter.) *
r Yes c' No
NEPA or SEPA Final Approval Letter
C7ick the upload button or drag and drop files here to attach docurrent
FlLE NFE MJST BE FOF
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)? *
f 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?*
C' Yes �' No
3b. If you answered "no," provide a short narrative description.
I 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?*
G Yes C' No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
C' Yes �' 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?*
Field surveys, NHP data, USFWS and NMFS websites
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
f Yes r No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
NMFS
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 �' No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?*
NEPA documentation
7c. Historic or Prehistoric Information Upload
Gick the upload button w drag and drop files here to attach docurrent
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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 C' No
8b. If yes, explain how project meets FEMA requirements:
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.
qick the upload button or drag and drop files here to attach docurrent
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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
i 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� ��Ilar
Date
10/26/2017
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*
20171369
Version#*
1
Reviewing Office*
Wilmington Regional Office - [phone]
Select Project Reviewer*
i Joanne Steenhuis:eads\jhsteenhuis