20171437 Ver 1_PCN Form Submission_20171108

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 11 /8/2017 4:40:45 PM (Start Event)
Accept by Carpenter,Kristi 11/8/2017 5:27:03 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: November 13, 2017 5:00 PM
11 /8/2017 4:41 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:*
Yadkin
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.11.R.143
(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.
14 - Linear transportation
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
For the record only for Corps Permit:
*
C' Yes C•' No
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
Acceptance Letter Attachment
qick the upload button or drag and drop files here to attach docurrent
SR 1710 - Bridge 10 - Division 11 - STR - YD 101 (warm).pdf
FlLE TYFE MJST BE FDF
1f. Is the project located in any of NC's twenty coastal counties?*
C' Yes C•' No
1h. Is the project located in a designated trout watershed?*
G No
C' Yes
�s�l�i�l:/:
Link to trout information: http://w�nn�v.saw.usace.army.mil/Missions/Regulatory-Permit-PrograrrUAgency-Coordination/Trout.aspx
6. Applicant Information
1a. Who is the Primary Contact?*
Heath Slaughter
1b. PrimaryContact Email:*
[e-mail]
1c. PrimaryContact Phone:*
(xxx)xxx-xxxx
[phone]
1d. Who is applying for the permit?
I7 Owner r Applicant (other than owner) r AgenUConsultant
(Check all that apply)
� 2. Owner I nformation
2a. Name(s) on recorded deed:
i NCDOT
2b. Deed book and page no.:
2c. Responsible party:
(for Corporations)
2d.Address
Street Address
801 Statesville Road
Address Line 2
a�y
North Wilkesboro
Fbstal / Zip Code
28659
State / R'ovince / F�gion
NC
Country
USA

2e. Telephone Number:
(xxx)xxx-xxxx
[phone]
2f. Fax Number:
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Replace Bridge #10, Yadkin
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:*
Yadkinville
1d. Driving directions*
If it is a new project and can not easily be found in a GPS rrapping system Rease provide directions.
See map
2. Project Identification
2a. Property Identification Number:
(tax RNor parcel ID)
2b. Propertysize:
(in acres)
0.5
2c. Project Address
Street Address
Address Line 2
�Y
Fbstal / Zip Code
State / R-ovince / 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 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:*
36.10638 N -80.58782 W
ex:34208504 -77.796371
3. SurFace Waters
3a. Name of the nearest body of water to proposed project:*
South Deep 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:*
Dilapidated bridge in rural residential/farming area.
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
Yadkin #10 Topo.pdf 134K6
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)
C7ick 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
4e. List the total estimated linear feet of all existing streams on the property:
(interrrittent and perennial)
— 200 linear feet
4f. Explain the purpose of the proposed project:
I Replace substandard bridge.
4g. Describe the overall project in detail, including the type of equipment to be used:
See attached cover letter.
4h. Please upload project drawings for the proposed project.
C7ick the upload button or drag and drop files here to attach docurrent
SF-980010_Permit Drawings.pdf 2.91 MB
Fle type rrust be pdf
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the propertyor proposed impact areas?*
C� Yes �' No �' Unknown
Comments:
5b. If the Corps made a jurisdictional determination, what type of determination was made? *
C' Preliminary �' Approved C' Unknown �' N/A
Corps AID Number:
Exarrple: SAV�2017-99999

Sc. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Othe r:
Heath Slaughter
NCDOT
Sd. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5d1. Jurisdictional determination upload
Gick the upload button or drag and drop files here to attach docurrent
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 C' 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 activit�/? This includes other separate and distant crossing for linear projects that require Department of the
Army authorization but don't require pre-construction notification.
NO
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 �J Streams-tributaries r Buffers
� 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.
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 #- Reason 3b.lmpact 3c. Type of 3d. Stream name * 3e. Stream Type * 3f. 3g. Stream 3h. Impact
for impact* type* impact* Jurisdictior�idth* length*
type *
14+90 - 16+06 It. P Relocatio UTto South Deep Creek Perennial Both 1 106
N�p label (e.g. Fd�ad F2rrranent (F) n F2rennial (Fff�) or interrrittent Average (feet) (linear feet)
CYossing1) orTerrporary (If�
��
14+90 - 16+06 It. T Dewaterin UTto South Deeep Perennial Both 1 25
N�p label (e.g. Fd�ad F2rrranent (F) g CPee k F�rennial (Fff� or interrrittent Average (feet) (linear feet)
Qossing1) orTerrporary (IfVn
i�

3a. Site #- Reason 3b.lmpact 3c. Type of 3d. Stream name *
for impact* type* impact*
16+04-16+48 P Bank South Deep Creek
N�p label (e.g. Fd�ad F2rrranent (F'� Stabilizati
CYossing 1) or Terrporary On
rn
16+04 - 16+48 T Dewaterin South Deep Creek
N�p label (e.g. Fd�ad F2rrranent (P� g
Q ossing 1) or Terrporary
i�i
3e. Stream Type * 3f. 3g. Stream 3h. Impact
Jurisdictior�idth* length*
type *
Perennial Both
F2rennial (F8� or interrrittent
(If�
Perennial Both
F2rennial (F9� or interrrittent
(IfV�
" 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:
148
3i. Total temporary stream impacts:
53
3i. Total stream and tributary impacts:
201
3j. Comments:
20 42
Average (feet) (linear feet)
20 28
Average (feet) (linear feet)
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:*
Avoiding the UT relocation would put a kink in the road. The terminal discharge point was retained to improve
stability of the proposed relocation.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
All appropriate BMPs will be used during 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)
106
4c. If using stream mitigation, what is the stream temperature:
warm
4d. Buffer mitigation requested (DWR only):
(squarefeet)
4e. Riparian wetland mitigation requested:
(acres)
4f. Non-riparian wetland mitigation requested:
(acres)
4g. Coastal (tidal) wetland mitigation requested:
(acres)
4h. Comments
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
1a. Does this project require a Stormwater Management Plan?
C�' Yes c' No
1b. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
See attached.
1c. What is the overall percent imperviousness of this project?
40
%
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 �' No

Stormwater Management Plan Upload
Gick 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?*
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
Comments:*
State MCC
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 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 C•' No
3b. If you answered "no," provide a short narrative description.
E�sting structure.
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.
i f�UA
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
Sa. 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 �' No
5d. Is another Federal agency involved?*
C' Yes C� No
Se. Is this a DOT project located within Division's 1-8?*
�' Unknown

C' Yes r No
5f. Will you cut anytrees in order to conduct the work in waters of the U.S.?*
�' Yes �' No
5g. Does this project involve bridge maintenance or removal?*
C� Yes C' No
Sg(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.
�' Yes �' 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 5g(1), did you discover anysigns of bat use?*
C' Yes G No C' Unknown
*** If yes, please show the location of the bridge on the permit drawings/project plans.
5h. Does this project involve the construction/installation of a wind turbine(s)?"*
C' Yes C•' No
5i. 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
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
Visual Observation and NHP database.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
f Yes C•' No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
I NOAA
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? *
� Project was reviewed by HEU.
7c. Historic or Prehistoric Information Upload
C7ick the upload button or drag and drop files here to attach docurrent
980010-15-03-0061_NoSurvey.pdf
980010-PA 15-03-0061 Yadkin (NHP).pdf
Fle rrust be FDF
8. Flood Zone Designation (Corps Requirement)
Link to the FEMA Floodplain Maps: https://msc.fema.gov/portal/search
3.49MB
7.65M6

8a. Will this project occur in a FEMA-designated 100-year floodplain?*
C' Yes C' No
8b. If yes, explain how project meets FEMA requirements:
I Project was reviewed and approved by NCDOT hydraulics engineers.
8c. What source(s) did you use to make the floodplain determination?*
FEMA Flood Map Service
Miscellaneous attachments not previously requested.
Gick the upload button or drag and drop files here to attach docurrent
NHP project_reportyadkin_bridge_10.pdf 845.4KB
Yadkin #10 Letter.pdf 511.85KB
Yadkin #10, NLEB.pdf 268.01 KB
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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.
i Full Name:*
Heath Slaughter
Signature
��`%� a�l��r�/��
Date :
current_date
Initial Review
Is this project a public transportation project? *(?)
C� Yes C' No
Change only if needed.
Has this project met the requirements for acceptance in to the review process?*
C� Yes
C' No
BIMS # Assigned*
20171437
Version#*
1
Reviewing Office *
Winston-Salem Regional Office - [phone]
Select Project Reviewer*

Dave Wanucha:eads\djwanucha