HomeMy WebLinkAbout20171516 Ver 1_PCN Form Submission_20171128Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 11/28/2017 10:16:43 AM (Start Event)
Accept by Carpenter,Kristi 11/28/2017 3:26:25 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: December 1, 2017 5:00 PM
11 /28/2017 10:17 AM
�� �
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:*
Halifax
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.84
(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 North Carolina (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
P.O. 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
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Bridge 185 SR 1616 Halifax Co.
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:*
Halifax
1d. Driving directions*
If it is a new project and can not easily be found in a C�5 rrapping system Rease provide directions.
Take exit 168 on I-95 Halifax County head east on NC 903 taking right on SR 1600 taking left on SR 1617 (Poplar Lane) taking right on SR
1616 (Hickory Drive) to bridge over Marsh Swamp
2. Project Identification
2a. Property Identification Number:
(tax RN or parcel ID)
2b. Propertysize:
(in acres)
2c. Project Address
Street Address
Address Line 2
Qty
Fbstal / Zip Code
State / FYovince / 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>cample, 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:* Longitude:*
36.34658 -77.67757
I ex:34.208504 -77.796371
3. SurFace Waters
3a. Name of the nearest body of water to proposed project:*
Marsh Swamp
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)
Qick the upload button or drag and drop files here to attach docurrent
Halifax 185 TOPO.pdf 1.24M6
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 a' 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:
0.06
4e. List the total estimated linear feet of all existing streams on the property:
(interrrittent and perennial)
100
4f. Explain the purpose of the proposed project:
Replace Bridge 185 which is structurally deficient for current NCDOT standards.
4g. Describe the overall project in detail, including the type of equipment to be used:
i Replace Bridge 185 which is structurally deficient for current NCDOT standards. Heavy road and bridge building
equipment will be used.
4h. Please upload project drawings for the proposed project.
aick the upload button or drag and drop files here to attach docurrent
Fle lype rrust be pdF
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the propertyor proposed impact areas?*
G Yes �' No �' Unknown
Comments:
5b. If the Corps made a jurisdictional determination, what type of determination was made?*
f Preliminary C' Approved �' Unknown C' fWA
Corps AID Number:
6carrple: SAVu2017-99999
Sc. If 5a is yes, who delineated the jurisdictional areas?
i Name (if known):
Agency/Consultant Company:
Othe r:
Chad Coggins
NCDOT
Sd. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5d1. Jurisdictional determination upload
C7ick 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 �' 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 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.
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 rJ Buffers
fJ Open Waters r Pond Construction
I 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 *
i impact*
Map label (e.g. Road
Crossing 1)
N�p label (e.g. Road Qossing 1)
Map label (e.g. Road
Crossing 1)
N�p label (e.g. F�ad Qossing 1)
Map label (e.g. Road
Crossing 1)
N�p label (e.g. Road Qassing 1)
Map label (e.g. Road
Crossing 1)
N�plabel(e.g.F�ad Qassing 1)
P Unknown
F2rrranent (Pj or Terrporary
��
T Unknown
F�rrranent (Fj or Terrporary
��
T Unknown
F�rrranent (P� or Terrporary
i�
T Unknown
F2rrranent (P� or Terrporary
i�
2g. Total Temporary Wetland Impact
0.050
2g. Total Permanent Wetland Impact
0.010
2g. Total Wetland Impact
0.060
2h. Comments:
2d. Wetland name * Ze. 2f. 2g. Impact
Forested* Jurisdiction area*
type *
site 1 fill No Both 0.010
(404, 10) or d�NR (acres)
(401, other)
site 1 temporary No Both 0.010
fill (404, 10) or d�NR (acres)
(401, other)
site 1 excavation No
site 1 hand No
clearing
Both 0.010
(404, 10) or D�NR (acres)
(401, other)
Both 0.030
(404, 10) or CM�R (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.
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 *
Map Label (e.g. T Dewaterin Marsh Swamp Perennial Both 45 51
Road Crossing 1) F�rrranent (P� g F2rennial (� or interrrittent Average (feet) (linearfeet)
N�p label (e.g. Fd�ad or Terrporary (IfVn
Qossing 1) �T�
*' 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:
0
3i. Total temporary stream impacts:
51
3i. Total stream and tributary impacts:
51
3j. Comments:
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 4b. Impact 4c. Name of waterbody* 4d. Activity 4e. Waterbody4f. Impact
i impact * type * type * type * area *
Map label (e.g. Road T Marsh Swamp Dewatering Tributary 0.01
I Crossing 1) F�rrrenent (� or (if applicable) (acres)
N�p label (e.g. I�ad Qossing 1) Terrporary (�
4g. Total temporary open water Impacts:
0.01
4g. Total permanent open water impacts:
0.00
4g. Total open water impacts:
0.01
4h. Comments:
� 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.
I6a. Project is in which protect basin(s)?*
Check all that apply.
r Neuse
r Catawba
I r Goose Creek
r Other
6b. Impact Type *
�J Tar-Pamlico
r Randleman
r Jordan Lake
6c. Per or 6d. Stream name *
Te mp *
Site 1 Bridge P Marsh Swamp
Location and C errpt, Allowable, allowable w/ rritigation F2rrranent (� or
Terrporary (�
Site 2 Bridge P Marsh Swamp
Location and Exerrpt, Allowable, allowable w/ rritigation F�rrrenent (F) or
Terrporary (�
Site 3 Bridge P Marsh Swamp
Location and 6cerrpt, Allowable, allowable w/ rritigation F�rrranent (P� a'
Terrporary (�
6h. Total buffer impacts:
6e. Buffer 6f. Zone 1 6g. Zone 2
mitigation impact* impact*
required?*
No 506 245
(squarefeet) (squarefeet)
No
No
46 0
(squarefeet) (squarefeet)
220 326
(squarefeet) (squarefeet)
Temporary impacts
I Permanent impacts:
Total buffer impacts
6i. Comments:
Zone 1
0.00
Zone 1
772.00
Zone 1
772.00
Supporting Documentation - i.e. Impact Maps, Plan Sheet, etc.
aick the upload button or drag and drop files here to attach docurrent
410185_Permit Drawings_20171031.pdf
410185_Permit Drawings_BUFFER 20171031.pdf
Fle rrust be FDF
Zone 2
0.00
Zone 2
571.00
Zone 2
571.00
E. Impact Justification and Mitigation
1. Avoidance and Minimization
1.75MB
878.63KB
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:*
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
�' 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 l" No
1b. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
The purpose of the project is to replace Bridge No. 185 on SR 1616 over Marsh Swamp in Halifax County. The
existing bridge is 46 feet long. The replacement structure will be a 1@ 30' and a 1@ 55' long bridge, providing a
27.83' clear deck width. The roadway grade of the new structure will be approximately the same as the epsting
structure. There will be no direct discharge into the stream (i.e. no deck drains on the bridge). The ewsting bridge
had two bents in the stream, while the proposed bridge has one. All existing stormwater drainage patterns v�re
maintained on the project to the fullest extent. The storm drainage system picking up the bridge deck drainage will
be outleted into a ditch in the southeast quadrant of the bridge. The ditches on the southwest and northeast
quadrants were retained and are outside of the e�asting right of way. Newditches have to be installed on the
northwest, and southeast quadrants since the existing ditches are being filled in by the proposed roadway
widening.
1c. What is the overall percent imperviousness of this project?
%
1d. Who will be responsible for the review of the Stormwater Management Plan?*
� Certified Local Government r DEMLR Stormwater Review
� DWR 401 & Buffer Permitting Branch rJ 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 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
N7 Other BMP
(check all that apply)
Diffused Flow Documentation
qick the upload button or drag and drop files here to attach docurrent
410185_diffuse flow plan.pdf 156.22KB
Fle lype rrust be FDF
5. DWR 401 Stormwater Review
Sa. Is the Stormwater Management Plan (including BMP Supplemental Forms and Operation and Maintenance Agreements) attached?
C•' Yes �' No
Stormwater Management Plan Upload
aick the upload button or drag and drop files here to attach docurrent
SF410185_SMP.pdf 31.34KB
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 �' No
Comments:*
MCDC available upon request.
� 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?*
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.
Replacing existing 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?*
G Yes C' No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
r Yes l" No
5c. If yes, indicate the USFWS Field Office you have contacted.
Raleigh
5d. Is another Federal agency involved?*
C' Yes C•' No
5e. Is this a DOT project located within Division's 1-8?*
C� Yes C' No
f Unknown
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
Freshwater Mussel and Fish Survey Report conducted by Three Oaks Engineering. Bio conclusion of MA-NLTAA
for TRSM, DWM, and Yellow Lance. Concurrence review requested on November 20, 2017, Gary Jordon FWS
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
C' Yes �' No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
i 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?*
HEU clearance
7c. Historic or Prehistoric Information Upload
aick the upload button or drag and drop files here to attach docurrent
16-11-0020_NoSurvey.pdf 1.91 MB
PA 16-11-0020 Halifax (NSR).pdf 7.86MB
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?*
�' Yes C' No
8b. If yes, explain how project meets FEMA requirements:
MOA approved
8c. What source(s) did you use to make the floodplain determination?*
NCDOT Hydro
Miscellaneous attachments not previously requested.
Qick the upload button or drag and drop files here to attach docurrent
Fle rrust be FDF
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.
Full Name:*
Chad Coggins
Signature
[!r�l� ��Q' jr�c�!tI
Date :
I 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*
i 20171516
Version#*
Reviewing Office *
Central Office - (919) 707-9000
Select Project Reviewer*
Rob Ridings:eads\rgridings