HomeMy WebLinkAbout20171436 Ver 1_PCN Form Submission_20171108Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 11 /8/2017 4:00:04 PM (Start Event)
Accept by Carpenter,Kristi 11/8/2017 4:17:02 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: November 13, 2017 5:00 PM
11 /8/2017 4:00 PM
�� �
6fvlslaa of Water Resources
Pre-Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
November 25, 2017 Ver 2.1
*
Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all mandatory questions are ans�red.
Below is a link to the online help file.
http://edocs.deq.nc.gov/WaterResources/0/doc/603610/Page1.aspx
A. Processing Information
County (or Counties) where the project is located:*
Edgecombe
Is this project a public transportation project? (?)
r Yes C' No
Is this a NCDOT Project?
C� Yes C' No
(NCDOT only) T.I.P. or state project number:
WBS #
17BP.4. R.81
(for NCDOT use only)
1a. Type(s) of approval sought from the Corps:
ri 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?
rJ 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: C' Yes C•' No
For the record only for Corps Permit: C' Yes r 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
i 1f. Is the project located in anyof NCs twentycoastal counties?*
C' Yes �' No
1h. Is the project located in a designated trout watershed?*
C� No
C' Yes
Link to trout information: http://v�uwv.saw.usace.army.mil/Missions/Regulatory-Permit-Program/Agency-Coordination/Trout.aspx
B. Applicant Information
1a. Who is the Primary Contact?*
Chad Coggins
1b. PrimaryContact Email:*
I tccoggins@ncdot.gov
1c. PrimaryContact Phone:*
(xxx)xxx-xxxx
(252)717-8699
1d. Who is applying for the permit?
� Owner rJ Applicant (other than owner) r AgenUConsultant
(Check all that apply)
2. Owner I nformation
2a. Name(s) on recorded deed:
State of NC (NCDOT)
2b. Deed book and page no.:
2c. Responsible party:
(for Corporations)
2d.Address
Street Address
Address Line 2
��
F�stal / Zip Code
2e. Telephone Number:
(xxx)xxx-xxxx
2f. Fax Number:
(xxx)xxx-xxxx
2g. Email Address:*
State / Rovince / Region
Country
tccoggins@ncdot.gov
3. Applicant Information (if different from owner)
3a. Applicant is:
C•' Agent
C' Other
If other please specify.
3b. Name:
Chad Coggins
3c. Business Name:
(if applicable)
NCDOT Div. 4
3d.Address
Street Address
PO Box 3165
Address Line 2
��
Wilson
Fbstal / Zip Code
27828
3e. Telephone Number:
(252)717-8699
(xxx)x�c-�ocx
3f. Fax Number:
(xxx)xxx-xxxx
3g. Email Address:*
� tccoggins@ncdot.gov
State / Rovince / F�gion
NC
Country
USA
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Bridge 113 SR 1102 Edgecombe Co.
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:*
Crisp
1d. Driving directions*
If it is a new project and can not easily be found in a C�5 rrapping system Rease provide directions.
Crisp south on US 258 1.5 miles turn west on Otter Creek Church Road south 0.5 miles
2. Project Identification
2a. Propertyldentification Number:
(tax RN or parcel ID)
2b. Propertysize:
i (in acres)
2c. Project Address
Street Address
Address Line 2
��
Fbstal / Zip Code
2d. Site coordinates in decimal degrees
SYate / R-ovince / Region
Country
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 example, 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:*
35.72239
ex:34208504
3. Surface Waters
Longitude:*
-77.63735
-77.796371
3a. Name of the nearest body of water to proposed project:*
Otter Creek
3b. Water Resources Classification of nearest receiving water:*
C; NSW
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Tar-Pamlico
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:*
Forestry and Agriculture are the predominant land uses in the vicinity of this 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)
C7ick the upload button or drag and drop files here to attach docurrent
Edge 113 topo.pdf 1013.25K6
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)
qick 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:
0.05
4e. List the total estimated linear feet of all existing streams on the property:
(interrrdtent and perennial)
100
4f. Explain the purpose of the proposed project:
Replace Bridge 113 which is structurally deficient for current NCDOT standards.
4g. Describe the overall project in detail, including the type of equipment to be used:
Replace Bridge 113 which is structurally deficient for current NCDOT standards. Heavy road and bridge building
equipment will be used.
I 4h. Please upload project drawings for the proposed project.
Gick the upload button or drag and drop files here to attach docurrent
Fle type rrust be pdF
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the propertyor proposed impact areas?*
r Yes C' No �' Unknown
Comments:
i 5b. If the Corps made a jurisdictional determination, what type of determination was made? *
C' Preliminary l" Approved r Unknown l" N/A
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:
Chad Coggins
NCDOT DEO
5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5d1. Jurisdictional determination upload
aick the upload button or drag and drop files here to attach docurrent
Fle type rrust be F�F
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
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
i impact*
Site 1
N�p label (e.g. 13�ad CXossing 1)
Site 1
N�p label (e.g. Fd�ad Qossing 1)
2b. Impact type * 2c. Type of wetland *
P Unknown
F�rrrenent (� or Terrporary
��
T Unknown
F�rrranent (P� or Terrporary
��
2g. Total Temporary Wetland Impact
0.040
2g. Total Permanent Wetland Impact
0.010
2g. Total Wetland Impact
0.050
2h. Comments:
2d. Wetland name * 2e. 2f. 2g. Impact
Forested* Jurisdiction area*
type *
site 1 fill No Both 0.010
(404, 10) or C7JVR (acres)
(401, other)
site 1 mechanize No Both 0.040
clearinng (404, 10) or d,NR (acres)
(401, other)
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.
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 Catawba
� Goose Creek
� Other
�J Tar-Pamlico
r Randleman
r Jordan Lake
6b. Impact Type *
6c. Per or 6d. Stream name *
Te mp *
Site 1 roadway P Otter Creek
Location and C errpt, Allowable, allowable w/ rritigation F2rrranent (P� or
Terrporary (�
Site 1 bridge P Otter Creek
Location and 6cerrpt, Allowable, allowable w/ rritigation F2rrranent (F� or
Terrporary (�
6h. Total buffer impacts:
Temporary impacts
Permanent impacts:
Total buffer impacts
6i. Comments:
Zone 1
0.00
Zone 1
2,381.00
Zone 1
2,381.00
Supporting Documentation - i.e. Impact Maps, Plan Sheet, etc.
Gick the upload button or drag and drop files here to attach docurrent
SF320113_Permit Drawings_BUFFER_20171004.pdf
SF320113_Permit Drawings_20171009.pdf
Fle rrust be FDF
Zone 2
0.00
Zone 2
973.00
Zone 2
973.00
E. Impact Justification and Mitigation
1. Avoidance and Minimization
6e. Buffer 6f. Zone 1 6g. Zone 2
mitigation impact* impact*
required?*
No 379 973
(squarefeet) (squarefeet)
No
596.48KB
917.07KB
2,002 0
(squarefeet) (squarefeet)
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:*
i Replace in place bridge with offsite detours
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
All construction equipment will be staged and operated from upland areas. DOT will also install silt fencing to
protect the streams and wetlands adjacent to project, and safety fencing will be used to delineate
jurisdictional/environmentally sensitive areas.
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
2b. If this project DOES NOT require Compensatory Mitigation, explain why:
� Belowthresholds for more than minor impact.
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
1a. Does this project require a Stormwater Management Plan?
�' Yes �' No
1b. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
i Replace bridge no. 113 over Otter Creek on SR 1102 Otter Creek Church Rd. Use 1@50', 1@55' 21" Cored Slab.
At end bridge, a TB 2GI will outlet outside the buffer zones on upstream side of the bridge with 15" RCP with Class
B rip rap used to stabilize the outlet. At begin bridge, a TB 2G1 will outlet into a ditch on the downstream side of the
bridge with 15" RCP with Class B rip rap used to stabilize the outlet. No deck drains will discharge directly into
channel.
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
�,7 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?
�' 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
r Other BMP
(check all that apply)
Diffused Flow Documentation
Gick the upload button or drag and drop files here to attach docurrent
SF320113 diffuse flow plan.pdf
Fle type rrust be f�F
5. DWR 401 Stormwater Review
217.99KB
5a. Is the Stormwater Management Plan (including BMP Supplemental Forms and Operation and Maintenance Agreements) attached?
C•' Yes
C' No
Stormwater Management Plan Upload
C7ick the upload button or drag and drop files here to attach docurrent
edge 113 smp.pdf
file type rrust be pdf
G. Supplementary Information
1. Environmental Documentation
51.87K6
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
Comments:*
MCDC available upon request.
C•' No
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 qualit�i?*
C' Yes �' No
3b. If you answered "no," provide a short narrative description.
I Replacing ebsting 2 lane bridge with new 2 lane bridge.
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 C•' No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
C' Yes C•' No
5d. Is another Federal agency involved?*
C' Yes �' No
5e. Is this a DOT project located within Division's 1-8?*
r Yes C' No
�' Unknown
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
no affect per mussel survey
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?*
GIS
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 �' No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?*
i HEU clearance
7c. Historic or Prehistoric Information Upload
C7ick the upload button or drag and drop files here to attach docurrent
16-11-0021 NothingEligOrAffected.pdf 395.52KB
Edgecombe113 LetterfromHPO.pdf 304.16KB
PA 16-11-0021 Edgecombe (NSR).pdf 6.31 MB
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8. Flood Zone Designation (Corps Requirement)
I 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 �' No
8b. If yes, explain how project meets FEMA requirements:
MOA approved
8c. What source(s) did you use to make the floodplain determination?*
FRIS
Miscellaneous attachments not previously requested.
C7ick the upload button or drag and drop files here to attach docurrent
Fle rrust be FDF
Signature
*
ri 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:*
Chad Coggins
Signature
� ff�l� ��P��C�!�
Date :
current_date
Initial Review
Is this project a public transportation project? *(?)
�' Yes C' No
Change only if needed.
Has this project met the requirements for acceptance in to the review process?*
�' Yes
C' No
BIMS # Assigned*
20171436
Version#*
Reviewing Office *
Central Office - (919) 707-9000
Select Project Reviewer*
Rob Ridings:eads\rgridings