20180243 Ver 1_PCN Form Submission_20180220

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 2/20/2018 1:49:14 PM (Start Event)
Accept by Carpenter,Kristi 2/20/2018 1:58:29 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: February 23, 2018 5:00 PM
2/20/2018 1:49 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)
January 31, 2018 Ver 2.3
*
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.
https://edocs. deq. nc.gov/WaterResources/0/edoc/624704/PCN%20Help%20File%202018-1-30. pdf
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:
176P.12.R.90
WBS #
� 46108.1.1
(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
ri 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:
For the record only for Corps Permit:
C•' Yes C' No
�' 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
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?
fJ Owner r Applicant (other than owner) r Agent/Consultant
(Check all that apply)
2. Owner I nformation
2a. Name(s) on recorded deed:
NCDOT
2b. Deed book and page no.:
2c. Responsible party:
(for Corporations)
Mark Stafford
2d.Address
Street Address
1710 East Marion Street
Address Line 2
Qty
Shelby
Fbstal / Zip Code
28151
2e. Telephone Number:
(xxx)xxx-xxxx
[phone]
2f. Fax Number:
[phone]
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
State / Rovince / F�gion
NC
Country
USA

C. Project Information and Prior Project History
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Replacement of Bridge #192 on SR 1662 (Will Dixon Road)
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:*
Lawndale
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 Lawndale, turn onto west main street (hwy 182) for —0.5 miles, turn left onto Casar-Lawndale Road for 0.6 miles, then turn right ont9o9
Belwood-Lawndale Road for 1.0 miles, turn right onto Will Dixon Road and proceed 0.3 miles to bridge site
2. Project Identification
2a. Property Identification Number:
(tax RNor 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
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:*
35.436355
ex:34208504
3. SurFace Waters
Longitude:*
-81.545428
-77.796371
3a. Name of the nearest body of water to proposed project:*
Maple Creek
3b. Water Resources Classification of nearest receiving water:*
WS-IV
Surface Water Lookup

3c. What river basin(s) is your project located in?*
Broad
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:*
Existing bridge on paved secondary road. Land use in vicinity is designated cropland/pasture
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
topo_map.pdf 172.68KB
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
20180219_06541906565_1_Soil_Map.pdf 519.06KB
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:*
To replace a 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:*
NCDOT proposes to replace Bridge #192, an e�asting three span (1 @30',2@ 30'3"), timber deck, timber I beam
bridge with a one span (1 @90'), 33" Box beam bridge. The project will be constructed using typical heavy
equipment (trackhoe, backhoe, etc.)
4h. Please upload project drawings for the proposed project.
Gick the upload button or drag and drop files here to attach docurrent
b5393_Permit_Drawings_Set_20180117.pdf 1.38M6
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5. Jurisdictional Determinations
Sa. Have the wetlands or streams been delineated on the propertyor proposed impact areas?*
C' Yes C' No C•' Unknown
Comments:
This project began as a central let project, some preliminary work done by
Erin Cheely prior to coming to division
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):

Sc. If 5a is yes, who delineated the jurisdictional areas?
Agency/Consultant Company:
Other
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
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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 Impacts Inventory
D. Proposed I m pacts I nventory
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
� Wetlands �7 Streams-tributaries r Buffers
r 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
I impacted.
3a. Site #- Reason for 3b.lmpact 3c. Type of impact* 3d. Stream name *
� impact* type*
1- From 13+80 to P Bank Stabilization Maple Creek
14+40 -L- F2rrranent (Pj or
N�p label (e.g. 13�ad Qossing 1) Terrporary (�
1- From 13+80 to T Workpad/Causew Maple Creek
I14+40 -L- F2rrraner�t (P� or ay
fv�p label (e.g. I�ad Qossing 1) Terrporary (�
3e. Stream
Type *
Perennial
F2rennial (F�Z) or
interrrittent (If�
Perennial
F2rennial (F�Z) or
irderrrittent (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:
30
3i. Total temporary stream impacts:
24
3i. Total stream and tributary impacts:
54
3j. Comments:
3f. Type of
Jurisdiction *
Both
Both
3g. Stream 3h. Impact
width* length*
25 30
Average (feet) (linear feet)
25 24
Average (feet) (linear feet)

E. Impact Justification and Mitigation
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:*
I To avoid direct discharge of bridge stormwater into the receiving waters, deck drains are not required for the
proposed bridge. Stormwater impacts have been minimized by utilizing grated inlets and pipe to collect bridge
stormwater to outlet on Class B riprap. The proposed rock plating in all four quadrants allowed 1.5:1 slopes to be
incorporated.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
Minimal impact to stream by removal of old bridge in sections.
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:
Timber bridge being replaced with a box beam 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 C•' No
For a list of options to meet the diffuse flow requirements, click here.
If no, explain why:
It is not located in an area with riparian buffers.
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?*
C�' Yes C' No

G. Supplementary Information
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:*
The project is listed as a type and class of activity wtiich qualifies as a Non-major action under 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)? *
f Yes r No
2b. Is this an after-the-fact permit application?*
C' Yes �' 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 qualit�i?*
C' Yes �' No
3b. If you answered "no," provide a short narrative description.
This is a minimum criteria projecUCE with little anticipated future impacts.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project? *
C' Yes C' No �' f�UA
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?*
r Yes �' 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?*
C� Yes C' No
What Federal Agency is involved?
USACE
�' Unknown

5e. Is this a DOT project located within Division's 1-8?*
C' Yes r No
5f. Will you cut anytrees in order to conduct the work in waters of the U.S.?*
C� Yes �' No
Sg. Does this project involve bridge maintenance or removal?*
C� Yes C' No
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 �' No
Link to the NLEB SLOPES document: http://sav�reg.usace.army.mil/NLEB/1-3Q17-signed_NLEB-SLOPES&apps.pdf
If you answered "Yes" to 5g(1), did you discover anysigns of bat use?*
C' Yes G 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.?*
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 Fleritage 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 Division 12 counties. See attached October 2016
memo from NES regarding NLEB.
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?*
Per Natural Heritage database, there are no salt marshes, oyster reefs, or seagrass beds in the vicinity of the
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 2017.
7c. Historic or Prehistoric Information Upload
C7ick the upload button or drag and drop files here to attach docurrent
17-05-0005 NoSu rveyReq. pdf
Cleveland 192 No Survey form.pdf
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8. Flood Zone Designation (Corps Requirement)
2.99M6
533.38KB

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
�' No
8c. What source(s) did you use to make the floodplain determination?*
NCDOT hydraulic coordination
Miscellaneous
Miscellaneous attachments not previously requested.
Gick the upload button or drag and drop files here to attach docurrent
B-5393 NLEB Cleveland.pdf
20180219_06575006407_1 _Farmland_Classification. pdf
b5393_hyd_erosion_control_package.pdf
hazardous_spill_basin.pdf
TE_memo.pdf
under_bridge.pdf
under_bridge2.pdf
upstream.pdf
downstream.pdf
cover_letter.pdf
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537.56KB
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4.49KB
138.21 KB
475.13KB
631.77KB
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Signature Page
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 "a
_ tr�I� a��:rl�+'

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*
20180243
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