20180072 Ver 1_PCN Form Submission_20180112

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 1/12/2018 1:22:10 PM (Start Event)
Accept by Carpenter,Kristi 1/12/2018 5:07:30 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: January 17, 2018 5:00 PM
1/12/2018 1:22 PM

E-PCN Submittal
���
�lulslaa af Water Resources
Pre-Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
December 15, 2017 Ver 2.2
*
Please note: fields marked with a red asterisk below are required. You will not be ab/e to submit the form until all mandatory questions are ans�red.
Also, if at any point you wish to print a copy of the E-PCN, all you need to do is right-click on the document and you can print a copy of the form.
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:*
Cleveland
Is this project a public transportation project? *(')
C�' Yes C' No
Is this a NCDOT Project?*
r Yes C' No
(NCDOT only) T.I.P. or state project number:
WBS #
17. BP.12. R.104
(for NCDOT use only)
1a. Type(s) of approval sought from the Corps:*
rJ 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?*
fJ Nationwide Permit (NWP)
r Regional General Permit (RGP)
Nationwide Permit (NWP) Number: 03 - Maintenance
NWP Number Other:
List all MNnurrbers you are applying for not on the drop down list.
1c. Type(s) of approval sought from the DWR:*

check all that apply
r% 401 Water Quality Certification - Regular r 401 Water Quality Certification - E�ress
r Non-404 Jurisdictional General Permit 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 l' No
For the record only for Corps Permit: �' Yes C' 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 �' No
1f. Is the project located in anyof NC's twentycoastal counties?*
C' Yes C•' No
1h. Is the project located in a designated trout watershed?*
f Yes C•' No
Link to trout information: http://w�nn�v.saw.usace.army.mil/Missions/Regulatory-Permit-PrograrrUAgency-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:
NC DOT Right of Way
2b. Deed book and page no.:
2c. Responsible party:
(for Corporations)
Mark Stafford
2d.Address
Street Address
1710 East Marion Street
Address Line 2
PO box 47
��
Shelby
Fbstal / Zip Code
28151
State / R-ovince / I�gion
NC
Country
USA

2e. Telephone Number:
(xxx)xxx-x�cx
[phone]
2f. Fax Number:
[phone]
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Replacement of Bridge #34 on SR 2033 in Cleveland County
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:*
Shelby
1d. Driving directions*
IF it is a new project and can not easily be found in a C�5 rrapping system Rease provide directions.
From US 74 in Shelby, head east towards Charlotte. Turn left on Bus 74 (Marion Street) at the lighted intersection. Turn right on to SR 2047
(Borders Road) at the next lighted intersection. Turn right at the stop sign on to SR 2033 (Oak Grove Road). Project will be the second
bridge approximately 1.5mi east.
2. Project Identification
2a. Propertyldentification Number:
(tax RN or parcel ID)
2b. Propertysize:
(in acres)
2c. Project Address
Street Address
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.)
i Latitude:*
35.272824
ex:34.208504
3. Surface Waters
Longitude:*
-81.446925
-77.796371

3a. Name of the nearest body of water to proposed project:*
Muddy Fork
3b. Water Resources Classification of nearest receiving water:*
Class C
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Broad
River Basin 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 Existing 160' long by 28' wide four span bridge. Land use around the project is mostly forested. Bridge is on paved
secondary road.
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)
C7ick the upload button or drag and drop files here to attach docurrent
TopoMap.pdf
Fle type rrust be pdF
3.82M6
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)
aick the upload button or drag and drop files here to attach docurrent
Soil_Map.pdf
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
K�.'L�f:3:/3
4f. Explain the purpose of the proposed project:*
I The purpose of the proposed work is to replace the deteriorating bridge for the safety of the travelling public.
4g. Describe the overall project in detail, including indirect imapacts and the type of equipment to be used:*
NC DOT proposes to replace Bridge No. 220034 on SR 2033 (Oak Grove Road) over Muddy Fork Creek in
Cleveland County west of Kings Mountain. E�sting 160' long by 28' wide four span bridge is to be replaced with a
170' long by 36' wide double span bridge. The proposed bridge will have no direct discharge into the water. All
stormwater runoff is discharged as far away from the stream and at the lowest velocities as practicable. Bank
stabilization will be added to both banks under bridge. A temporary workpad will be needed to install interior bent.
All Best Management Practices will be utilized during the course of the project. The project will be constructed
using typical heavy equipment (trackhoe, backhoe, etc).
4h. Please upload project drawings for the proposed project.
qick the upload button or drag and drop files here to attach docurrent
SF-220034_Permit Drawings_20180105.pdf 1.1MB
Fle type rrust be pdf
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the propertyor proposed impact areas?*
r Yes C' No �' Unknown
Comments:

Division 12 Environmental Office
5b. If the Corps made a jurisdictional determination, what type of determination was made? *
C' Preliminary C' Approved C' Unknown C•' WA
Corps AID Number:
Exarrple: SAVw2017-99999
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known): Division 12 Environmental Office
Agency/Consultant Company:
Othe r:
NC DOT
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 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
I 1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
r Wetlands rJ Streams-tributaries r Buffers
� Open Waters r Pond Construction
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 for 3b.lmpact 3c. Type of impact* 3d. Stream name * 3e. Stream 3f. Type of 3g. Stream 3h. Impact
impact� type* Type� Jurisdiction* width* length*
14+14/14+18 Bridge P Bank Stabilization Muddy Fork Creek Perennial Both 30 39
N�p label (e.g. f�ad Q'ossing 1) F2rrrnnent (P'j or F2rennial (FH�) or Average (feet) (linear feet)
Terrporary (� interrrittent (If�

3a. Site #- Reason for 3b.lmpact 3c. Type of impact* 3d. Stream name *
impact * type *
14+14/14+34 Bridge T Workpad/Causew Muddy Fork Creek
N�p label (e.g. I�ad Qossing 1) F�rrranent (Fj or ay
Terrporary (�
3e. Stream 3f. Type of 3g. Stream 3h. Impact
Type* Jurisdiction* width* length*
Perennial Both 30 64
F�rennial (�2) or Average (feet) (linear feet)
interrrittent (IfVn
*' 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:
39
3i. Total temporarystream impacts:
64
3i. Total stream and tributary impacts:
103
3j. Comments:
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:*
The proposed bridge will have no direct discharge into the water. The minimum number of deck drains necessary
to maintain safe passage by the traveling public will be installed over the overbank floodplain areas as far from the
stream as possible and diffused on riprap dissipators. Stormwater runoff from the proposed bridge is to flowto
traffic bearing grated inlets at the northwest end of the bridge where it will be diffused with a riprap pad at the
proposed pipe outlet. All proposed stormwater runoff is discharged as far away from the stream and at the lowest
velocities as practicable.
i 1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
Minimi�ation of impacts by installing appropriate erosion control measures. Minimal impact to stream during old
bridge removal.
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:
Four span bridge replacement with a double span bridge.
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
""� Recent changes to the stormwater rules have required updates to this section .*'�
1. Diffuse Flow Plan
1a. 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
For a list of options to meet the diffuse flow requirements, click here.

If no, explain why:
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?*
�' Yes C' No
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:*
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 �' No
2b. Is this an after-the-fact permit application?*
C' Yes C•' No
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.
The project is a Minimum criteria project with little anticipated future impacts.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project? *
C' Yes C� No C' f�/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?*
C� Yes l" No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
C� Yes �' No
5c. If yes, indicate the USFWS Field Office you have contacted.
Asheville

5d. Is another Federal agency involved?*
r Yes C' No
What Federal Agency is involved?
USACE
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.?*
r 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.
r 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 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 �' 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?*
NC Natural Heritage Program 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 from 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?*
Per Natural Heritage database no salt marshes, oyster reefs, or seagrass beds located in vicinity of project.
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 C•' No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources? *
Cultural resources reviewconducted 2016
7c. Historic or Prehistoric Information Upload

C7ick the upload button or drag and drop files here to attach docurrent
CR_Arch.pdf
CR_Historic.pdf
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?*
�' Yes �' No
8b. If yes, explain how project meets FEMA requirements:
NCDOT hydraulic coordination
8c. What source(s) did you use to make the floodplain determination?*
Flood map website, http://fris.nc.gov/fris
Miscellaneous
Miscellaneous attachments not previously requested.
C7ick the upload button or drag and drop files here to attach docurrent
Flood.pdf
Bat Assessment.pdf
FIg1.pdf
FIg2.pdf
B#34_OakGrove_RD_TE. pdf
cover_letter.pdf
Hazardous Spill Checklist.pdf
photo1_2.pdf
Photo3_4.pdf
StreamlinedConsultationForm29Feb2016.pdf
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Signature
*
r% By checking the box and signing below, I certify that:
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■ 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:*
Jeffrey L. Wyatt
Signature
�7 `�. ��.�!� �1• ���%f•z'-
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*
20180072
Version#*
1
Reviewing Office *
Mooresville Regional Office - [phone]
Select Project Reviewer*
Donna Hood:eads\drhood
Is a payment required for this project?*
C� No payment required
f Fee received
C' Fee needed - send electronic notification