20171465 Ver 1_PCN Form Submission_20171115

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 11/15/2017 3:23:45 PM (Start Event)
Accept by Carpenter,Kristi 11/15/2017 4:50:21 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: November 20, 2017 5:00 PM
11/15/2017 3:24 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:*
Stokes
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:
840129
WBS #
17BP.9. R.61
(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.
13 - Bank Stabilization
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
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?*
Amy Euliss
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 Division 9
2b. Deed book and page no.:
i N/A
2c. Responsible party:
(for Corporations)
f�UA
2d.Address
SYreet Address
375 Silas Creek Parkway
Address Line 2
��
Winston Salem
Fbstal / Zip Code
27127
2e. Telephone Number:
(xxx)xxx-xxxx
[phone]
State / R-ovince / F�gion
NC
Country
USA

2f. Fax Number:
(xxx)xxx-x�cx
2g. Email Address:*
[e-mail]
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
� Bridge Replacement 840129
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:*
Mt. Airy
1d. Driving directions*
If it is a new project and can not easily be found in a G� rrapping system Rease provide directions.
N 36.427700 deg.
W -80.294275 deg.
2. Project Identification
2a. Property Identification Number:
(tax RNor parcel ID)
wa
2b. Propertysize:
(in acres)
wa
2c. Project Address
Street Address
wa
Address Line 2
�Y
Fbstal / Zip Code
State / Rovince / F�gion
Country
2d. Site coordinates in decimal degrees
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.)
Latitude:*
36.427700
ex:34.208504
3. Surface Waters
Longitude:*
-80.294275
-77.796371
3a. Name of the nearest body of water to proposed project:*
South Double Creek

3b. Water Resources Classification of nearest receiving water:*
B
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Roanoke
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:*
Transportation facility with surrounding rural, residential, and agricultural land use.
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
USGS Excerpt.pdf 1011KB
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
NRCS Excerpt.pdf 170.29KB
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)
90
4f. Explain the purpose of the proposed project:
I Replacement of Bridge 129
4g. Describe the overall project in detail, including the type of equipment to be used:
Replace an existing 3-span, 115' total length bridge with a 3-span, 145' total length bridge on the same alignment.
an off-site detour will be utilized and standard bridge construction operations will be employed. No temporary
causeways or work bridges are proposed.
4h. Please upload project drawings for the proposed project.
Gick the upload button or drag and drop files here to attach docurrent
840129_Permit Drawings_20160915.pdf 1.52M6
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 f" Unknown
Comments:
Sb. If the Corps made a jurisdictional determination, what type of determination was made? *
C' Preliminary C' Approved C' Unknown �' f�UA
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:
5d. 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 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 �' 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):
� Wetlands fJ 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 *
for impact* type* impact*
1- Riprap at P Bank
Embankment F�rrranent(Fj Stabilizati
N�p label (e.g. Fd�ad (�Terrporary On
Qossing 1)
South Double Creek
3e. Stream Type * 3f. 3g. Stream 3h. Impact
Jurisdictior�idth* length*
type *
Perennial Corps 20 54
F�rennial (� or interrrittent Average (feet) (linear feet)
QfVf)
"" 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:
54
3i. Total temporarystream impacts:
0
3i. Total stream and tributary impacts:
54
3j. Comments:
All impacts associated with bank stabilization.
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
I 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:*
Replace in-place was incorporated to minimize impacts. Bridge length has been extended to provide additional
setbacks from stream banks, and no piers are proposed in surface-waters. Riprap at embankments is proposed
for relocation of existing ditches discharging to surface-waters.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
NCDOT Best Management Practices for Construction and Maintenance Activities will be employed.
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:
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:

This project involves the replacement of Bridge Number 840129 over South Double Creek on SR 1484 (Dan
George Road) and improvements to the roadway approaches in each direction. The bridge replacement and
associated approaches have been designed to minimize increases in impervious surface area and maintain
e�asting drainage patterns. No deck drains are proposed for the replacement bridge. Deck drainage will be
collected by grate inlets at the roadway sag location north of the bridge and discharged to a roadway ditch on the
east side of the road. A rip-rap outlet pad will be installed at the discharge pipe to protect against erosion.
Proposed ditches on the northeast and southwest quadrants of the bridge are intended to replace existing
roadway ditches that will be covered by shoulder fill material, and are of similar size and grade to the e�asting
ditches they will replace. Rip-rap ditch linings are proposed for all or portions of the proposed ditches to control
runoff velocity and erosion.
1c. What is the overall percent imperviousness of this project?
38
%
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:
Roanoke River Basin
C•' No
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
840129_HYD_SMPv2.06_20160915 (June 2016).pdf
file type rrust be pdf
G. Supplementary Information
1. Environmental Documentation
f��.^�if�a:/:
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
Comments:*
f�llA
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
C•' No
2b. Is this an after-the-fact permit application?*

r Yes r 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 C•' No
3b. If you answered "no," provide a short narrative description.
Due to minimal transportation impact from this bridge replacement this project will neither influence nearby land
use 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.
� 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?*
G Yes l' No
5c. If yes, indicate the USFWS Field Office you have contacted.
Asheville
5d. Is another Federal agency involved?*
C' Yes C' No
What Federal Agency is involved?
USFWS. See attached MANLAA concurrence regarding the James Spiny
Mussel.
5e. Is this a DOT project located within Division's 1-8?*
C' Yes C•' No
Sf. Will you cut anytrees in order to conduct the work in waters of the U.S.?*
C' Yes C� No
5g. Does this project involve bridge maintenance or removal?*
r Yes C' No
C' Unknown
5g(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 5g(1), did you discover any signs of bat use?*
C' Yes C•' 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 r 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.?*
�' Yes C' No
If yes, please provide details to include type of percussive activity, purpose, duration, and specific location of this activity on the
pro pe rty.
C7ick the upload button or drag and drop files here to attach docurrent
Fle rrust be FDF
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
Field Surveys and USFWS County List.
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?*
NOAA EFH Mapper
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? *
See attached 'No Effects' determinations
7c. Historic or Prehistoric Information Upload
Gick the upload button or drag and drop files here to attach docurrent
840129_14-11-0002NoSurveyReq. pdf 1.7MB
Structure 840129 Stokes No NRHP Archaeological Sites Present Form.pdf 2.01 MB
Fle rrust be FDF
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?*
C� Yes l" 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 DFIRM
Miscellaneous attachments not previously requested.
aick the upload button or drag and drop files here to attach docurrent
15-030 Stokes Co Br 129.pdf 1.34M6
Br 129 Dan George Road (SR 1484) Stokes Concurrence request.pdf 768.66KB
Brg_129_Permit_Cover_Letter.doc.pdf 255.17KB
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:*
Amy Euliss
Signature
��%r fCj.l!/r.t�
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*
20171465
Version#*
1
Reviewing Office*
Winston-Salem Regional Office - [phone]
Select Project Reviewer*
Dave Wanucha:eads\djwanucha