20171582 Ver 1_PCN Form Submission_20171212

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 12/12/2017 12:53:52 PM (Start Event)
Accept by Carpenter,Kristi 12/12/2017 3:34:08 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: December 15, 2017 5:00 PM
12/12/2017 12:54 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:*
Gaston
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.12.R.89
(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
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?*
Trish Beam
1b. Primary Contact 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)
Mark Stafford
2d.Address
SYreet Address
1710 East Marion Street
Address Line 2
PO Box 47
��
Shelby
Fbstal / Zip Code
28151
2e. Telephone Number:
SYate / R-ovince / F�gion
North Carolina
Country
United States

(xxx)xxx-x�cx
[phone]
2f. Fax Number:
I [phone]
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Bridge #172 Replacement
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:*
I High Shoals
1d. Driving directions*
IF it is a new project and can not easily be found in a GPS rrapping system Rease provide directions.
From the Town of High Shoals head south on N Lincoln St, Turn left onto Thompkins St, Continue onto Dallas Rd, Continue onto Old Hardin
Rd, Turn right onto Philadelphia Church Rd, Turn left onto Alexis High Shoals Rd
2. Project Identification
2a. Property Identification Number:
(tax RN or parcel ID)
2b. Propertysize:
(in acres)
2c. Project Address
Street Address
Address Line 2
�Y
Fbstal / Zip Code
State / FYovince / 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.)
I Latitude:*
35.398656
ex:34208504
3. Surface Waters
Longitude:*
-81.171712
-77.796371
3a. Name of the nearest body of water to proposed project:*
Hoyle Creek

3b. Water Resources Classification of nearest receiving water:*
WS-IV
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Catawba
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:*
Exisitng timber bridge on paved secondary road. Land us in vicinity is designated forest land.
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
Quad Map.pdf 676.5KB
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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
Soil_Map.pdf 326.79KB
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)
100
4f. Explain the purpose of the proposed project:
I Replacement of a deteriorating bridge for the safety of the travelling public.
4g. Describe the overall project in detail, including the type of equipment to be used:
NCDOT proposes to replace an ewsting 3 span, 23.5 feet wide, 90.5 feet long timber bridge with a 39 foot wide,
105 foot long single box beam bridge. The proposed bridge will incorporate sloped abutments. The project will be
constructed using typical heavy equipment (backhoes, trackhoes, etc)
4h. Please upload project drawings for the proposed project.
Gick the upload button or drag and drop files here to attach docurrent
350172 Permit Drawings.pdf 2.26M6
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5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the propertyor proposed impact areas?*
C' Yes C' No f" Unknown
Comments:
I Division 12 Environmental Office
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:
I 6carrple: SAV�2017-99999

5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Othe r:
Division 12 Environmental Office
NCDOT
5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
9/14/17
5d1. Jurisdictional determination upload
Gick the upload button or drag and drop files here to attach docurrent
JD.pdf
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6. Project History
E�C�c�1:/:
6a. Have permits or certifications been requested or obtained for this project (including all prior phases) in the past?*
C' Yes �' No f" Unknown
7. Future Project Plans
7a. Is this a phased project?*
C' Yes r 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
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.
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) -L- 15+17, Bank P Bank Hoyle Creek
stabilization at F�rrranent(�j Stabilizati
Ditch Outlet (�Terrporary on
fv�p label (e.g. Id�ad
C7ossing 1)
3e. Stream Type * 3f. 3g. Stream 3h. Impact
Jurisdictior�idth* length*
type *
Perennial Both 25 12
F�rennial (�) or interrrittent Average (feet) (linear feet)
QfV�

3a. Site #- Reason 3b.lmpact 3c. Type of 3d. Stream name *
for impact* type* impact*
1) -L- 15+17, Bank T Bank Hoyle Creek
stabilization at F2rrranent(P� Stabilizati
Ditch Outlet ��Terrporary on
fv�p label (e.g. 13�ad
Qossing 1)
1) -L- 15+40, P Bank Hoyle Creek
Additional Bank F�rrranent(f� Stabilizati
Stabilization under ��Terrporary on
Bridge
N�p label (e.g. 13�ad
Qossing 1)
1) -L- 15+40, Bank T Bank Hoyle Creek
Stabilization under F�rrranent(Fj Stabilizati
Bridge (�Terrporary on
fv�p label (e.g. I�ad
Qossing 1)
3e. Stream Type * 3f. 3g. Stream 3h. Impact
Jurisdictior�idth* length*
type *
Perennial Both
F2rennial (F8� or interrrittent
QfV�
Perennial Both
f�rennial (F�2) or interrrittent
(IfVT)
Perennial Both
F2rennial (F9� or interrrittent
(If�
"" 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:
21
3i. Total temporarystream impacts:
40
3i. Total stream and tributary impacts:
61
3j. Comments:
The exsting concrete footing along each bank will be retained and utilized as the "face" of riprap bank
stabili�tion, which will be placed upslope. An additional 9 feet of riprap bank stabilization is necessary since the
proposed bridge is wider than the e�sting bridge.
25 20
Average (feet) (linear feet)
25 9
Average (feet) (linear feet)
25 20
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
I 1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:*
Runoff from the bridge will be captured and discharged at then end of the bridge onto Class B riprap
1b. Specificallydescribe measures taken to avoid or minimize the proposed impacts through construction techniques:*

Construction equipment w�orking from banks to remove old bridge and construct new bridge.
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:
Bridge to bridge replacement
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
1a. Does this project require a Stormwater Management Plan?
C•' Yes �' No
1b. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
See attached stormwater management spreadsheet
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
N7 DWR 401 & Buffer Permitting Branch r 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?
�' Yes G 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?
�' Yes C' No
Stormwater Management Plan Upload
Qick the upload button or drag and drop files here to attach docurrent
i 350172_HYD_SMPv2 07.pdf 180.42KB
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?*
�' 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 G No
Comments:*

The project is listed as a type and class of activity which qualifies as a Non-major action under the Minimum
Criteria Rules; therefore, a minimum criteria checklist has been completed for the bridge replacement project.
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.
The project is a minimum criteria project, with little anticipated future impacts.
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 No wastewater is generated from the project.
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?*
�' Yes C' 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?
USACE
5e. Is this a DOT project located within Division's 1-8?*
C' Yes C� No
5f. Will you cut any trees 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?*
�' Yes C' No
f" 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://saw-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 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.?*
C' Yes C•' No
Sj. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
NC Natural Heritage database and on site surveys. Division 12 is located in the white nose syndrome area;
however, there are no known hibernacula or roosting trees in the Division 12 counties, therefore, a NLEB
consultation form was completed (see attached).
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?*
There are no salt marshes, oyster reefs, or seagrass beds in the Cleveland, Lincoln, Gaston, Catawba, Ale>cander,
or Iredell counties.
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?*
Cultural resources reviewconducted in 2010 and 2017
7c. Historic or Prehistoric Information Upload
C7ick the upload button or drag and drop files here to attach docurrent
09-11-0015Update_NoSurveyReq. pdf
Gaston 172 No Survey Required form.pdf
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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:
i NCDOT hydraulic coordination
8c. What source(s) did you use to make the floodplain determination?*
Flood map website, http://fris.nc.gov/fris
4.19M6
2.18M6

Miscellaneous attachments not previously requested.
C7ick the upload button or drag and drop files here to attach docurrent
FloodMap.pdf 360.69KB
NRTR_Memo.pdf 247.32KB
BatHabitatAssessmentForm.pdf 44.71 KB
signed_NLEB_consultation_form.pdf 98.02K6
under_bridge.pdf 333.92KB
under_bridge2.pdf 320.7K6
hazardous_spill_checklist.pdf 4.51 KB
cover_letter.pdf 227.66KB
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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:*
Trish Beam
Signature
F "�
_ 2 c�I� r�£.-Y�ls�'
Date :
current_date
Initial Review
Is this project a public transportation project? *(?)
�' Yes �' No
Change only if needed.
Has this project met the requirements for acceptance in to the review process?*
�' Yes
C' No
BIMS # Assigned*
20171582
Version#*
1
Reviewing Office *
Mooresville Regional Office - [phone]
Select Project Reviewer*
i Donna Hood:eads\drhood