20171569 Ver 1_PCN Form Submission_20171208

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 12/8/2017 10:16:07 AM (Start Event)
Accept by Carpenter,Kristi 12/8/2017 3:18:46 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: December 13, 2017 5:00 PM
12/8/2017 10:16 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:*
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:
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

2f. Fax Number:
[phone]
(xxx)x�c-�ocx
2g. Email Address:*
[e-mail]
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Bridge Replacement #840086 on SR 1651 over Snow Creek
1b. Subdivision name:
(if appropriate)
wa
1c. Nearest municipality/town:*
Lawsonville
1d. Driving directions*
IF it is a new project and can not easily be found in a GPS rrapping system Rease provide directions.
Take NC-8 north from Winston-Salem for approximately 17 miles. Turn left onto Gene Martin Road for one mile. Turn left onto NC-8 f�UNC-89
W for 2.3 miles. Turn right onto Sheppard Mill Road for 4.3 miles. Turn left onto Moir Farm Road for 3.2 miles. Turn left onto Snow Hill
Church Road for 1.2 miles to get to bridge 840086 over Snow Creek. N 36.483355 deg; W-80.174458 deg.
2. Project Identification
2a. Propertyldentification Number:
(tax RN or parcel ID)
wa
2b. Propertysize:
(in acres)
wa
2c. Project Address
Street Address
SR 1651 over Snow Creek
Address Line 2
��
Lawsonville
Fbstal / Zip Code
2d. Site coordinates in decimal degrees
State / Rovince / f�gion
NC
Country
USA
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:*
36.483355
ex:34208504
3. Surface Waters
Longitude:*
-80.174458
-77.796371

3a. Name of the nearest body of water to proposed project:*
Snow Creek
3b. Water Resources Classification of nearest receiving water:*
C
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:*
I E�sting conditions indude SR 1651 (Snow Hill Church Road) and Bridge #840086, undeveloped forest, residential
development and disturbed/maintained right-of-way.
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_Bridge086_StokesCo.pdf 1.81 MB
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
Soils_Bridge086_StokesCo.pdf 360.01 KB
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)
210
4f. Explain the purpose of the proposed project:
To replace Bridge #840086 with an improved, modern structure consisting of a 170' three-span bridge.
4g. Describe the overall project in detail, including the type of equipment to be used:
� Erosion and sedimentation control measures will be installed. The bridge replacement will use track hoes, cranes,
dump trucks, bulldozers, paving equipment, water pumps, sandbags and various hand tools.
4h. Please upload project drawings for the proposed project.
aick the upload button or drag and drop files here to attach docurrent
086- Permit Drawings.pdf 1.71 MB
Fle type rrust be pdf
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the propertyor proposed impact areas?*
�' Yes C' No �' Unknown
Comments:
5b. If the Corps made a jurisdictional determination, what type of determination was made? *
C' Preliminary c' Approved C' Unknown C•' 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:
Amy Euliss
NCDOT Division 9
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 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 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):
� Wetlands I7 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*
bridge P Bank Snow Creek
replacement F2rrranent(P� Stabilizati
fv�p label (e.g. Fd�ad (�Terrpo�ary on
C7ossing 1)
3e. Stream Type * 3f. 3g. Stream 3h. Impact
Jurisdictior�idth* length*
type *
Perennial Corps 20 206
F2rennial (F8� or interrrittent Average (feet) (linear feet)
QfV�
"" 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:
206
3i. Total temporarystream impacts:
0
3i. Total stream and tributary impacts:
206
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
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:*
Permanent impacts to Snow Creek are unavoidable due to the requirement to remove and replace the bridge and
stabilize the stream banks. The placement of the bridge from the stream embankments will eliminate the need for
heavy equipment to enter the jurisdictional waters of the U.S. and will allow demolition of the ebsting bridge with
minimal impacts to the stream channel.
1b. Specificallydescribe measures taken to avoid or minimize the proposed impacts through construction techniques:*
Construction of the bridge will take place from the roadway approaches which will minimize stream impact. The
stream bank stabilization has been minimized to the greatest extent possible; an off-site detour will be used.
I 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:

The stream banks will be stabilized with minimal impact to the stream bed and no loss of jurisdictional waters of the U.S. NCDOT Best
Management Practices for Construction and Maintenance Activities will be employed.
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 SMP.
1c. What is the overall percent imperviousness of this project?
0
%
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
If no, explain why:
No protected riparian buffers in the Roanoke River basin.
5. DWR 401 Stormwater Review
5a. Is the Stormwater Management Plan (including BMP Supplemental Forms and Operation and Maintenance Agreements) attached?
�' Yes l" No
Stormwater Management Plan Upload
C7ick the upload button or drag and drop files here to attach docurrent
086- Permit Drawings.pdf 1.71 MB
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 �' 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:*
An environmental document is not required per SEPA. A state Minimum Criteria Checklist is being prepared.
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 quality?*
C' Yes �' No
3b. If you answered "no," provide a short narrative description.
Project involves the replacement of an ewsting bridge structure and is not anticipated to have any significant
impact on future development.
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.
N/A
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?*
�' Yes �' No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
C� Yes C' No
Sc. If yes, indicate the USFWS Field Office you have contacted.
Asheville
5d. Is another Federal agency involved?*
C' Yes C� No
5e. Is this a DOT project located within Division's 1-8?*
C' Yes G No
5f. Will you cut anytrees in order to conduct the work in waters of the U.S.?*
�' Yes C' No
5g. Does this project involve bridge maintenance or removal?*
C•' 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.
�' Yes C' No
Link to the NLEB SLOPES document: http://sav�reg.usace.army.mil/NLEB/1-30-17-signed_NLEBSLOPES&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 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.?*
�' Yes C' No
If yes, please provide details to include type of percussive activity, purpose, duration, and specific location of this activity on the
prope rty.
C7ick the upload button or drag and drop files here to attach docurrent
Fle rrust be FDF
I 5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
NC Natural Fleritage Program, USFWS, field surveys.
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?*
NOAA EFH Webpage
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?*
NCDOT Cultural Historians. see attached 'No Effects' determinations.
7c. Historic or Prehistoric Information Upload
C7ick the upload button or drag and drop files here to attach docurrent
840086_14-11-0004NoSurveyReq. pdf 1.79M6
Structure 840086 Stokes No NRHP Archaeological Sites Present Form.pdf 2.17M6
Fle rrust be f�F
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 C' No
8b. If yes, explain how project meets FEMA requirements:
Hydraulic calculations have been prepared based on the placement of the new cored slab bridge. No increase in
� the upstream flood elevations is anticipated based on these calculations. Based on the results of the HEGRAS
model for SR 1651 over Snow Creek, the existing bridge can be replaced without causing a rise to the established
100-year flood elevations and meets the requirements of Federal Highway Administration, Federal-Aid Policy
� Guide, 23 CFR 650A Location and Hydraulic Design of Encroachments on Floodplains and the NCDOT MOA.
8c. What source(s) did you use to make the floodplain determination?*
FEMA FIRM maps on-line
Miscellaneous attachments not previously requested.
Qick the upload button or drag and drop files here to attach docurrent
Brg 086 Permit Cover Letter.doc.pdf 267.12KB
Fle rrust be FDF

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
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, Div 9 EO
Signature
�fr� [j.11l itc7
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*
20171569
Version#*
1
Reviewing Office *
Winston-Salem Regional Office - [phone]
Select Project Reviewer*
I Dave Wanucha:eads\djwanucha