20180401 Ver 1_PCN Form Submission_20180321

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 3/21/2018 9:58:53 AM (Start Event)
Accept by Carpenter,Kristi 3/21/2018 11:06:15 AM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: March 26, 2018 5:00 PM
3/21 /2018 9:59 AM

�� �
�ivislan af Water Resour�es
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 beloware required. You will not be able 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:*
Wayne
Is this project a public transportation project?* (')
C Yes l' No
Is this a NCDOT Project?*
f• Yes r No
(NCDOT only) T.I.P. or state project number:
WBS #
17BP.4. R.87
(for f�D�T use only)
1a. Type(s) of approval sought from the Corps:*
I7 Section 404 Permit (wetlands, streams and waters, Clean Water Act)
I-' 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
NWP Number Other:
List all MN nurrbers you are applying for not on the drop down list.
03 - Maintenance
1c. Type(s) of approval sought from the DWR:*
check all that apply
fJ 401 Water Quality Certification - Regular
r Non-404 Jurisdictional General Permit
r 401 Water Quality Certification - Express
�J Riparian Buffer Authorization

*
1d. Is this notification solelyfor the record because written approval is not required?
For the record onlyfor DWR 401 Certification: C' Yes �' No
For the record onlyfor Corps Permit: C' Yes f' 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
l' Yes r No
1f. Is the project located in anyof NC's twentycoastal counties?*
f Yes �' No
1h. Is the project located in a designated trout watershed?*
C' Yes C No
Link to trout information: http://www.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:*
[e-mail]
1c. PrimaryContact Phone:*
(xxx)xxx-xxxx
[phone]
1d. Who is applying for the permit?
r Owner r% Applicant (other than owner) r Agent/Consultant
(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
a�y
Fbstal / Zip Code
2e. Telephone Number:
(xxx)xxx-xxxx
2f. Fax Number:
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
3. Applicant Information (if different from owner)
State / Rrnince / F�gion
Country

3a. Applicant is:
r Agent
f' Other
If other please specify.
3b. Name:
Chad Coggins
3c. Business Name:
(rf applicable)
NDOT Div 4
3d. Address
Street Address
P.O. Box 3165
Address Line 2
a�y
Wilson
Fbstal / Zip Code
27828
3e. Telephone Number:
[phone]
(xxx)xxx-xxxx
3f. Fax Number:
(xxx)xxx-xxxx
3g. Email Address:*
[e-mail]
State / Rovince / f�gion
NC
Country
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Bridge 15 SR 1719 Wayne Co.
1b. Subdivision name:
('rf appropriate)
1c. Nearest municipality/ town:*
Goldsboro
1d. Driving directions*
If it is a new project and can not easily be found in a GPS rrapping system Rease provide directions.
Take Parkstown Road ext on US 70 BYP southeast of Goldsboro drive east to SR 1719 (N. Beston Road), turn right drive 2 miles south to
Bridge 15 over West Bear Creek.
2. Project Identification
2a. Propertyldentification Number:
(tax RNor parcel ID)
2b. Propertysize:
(in acres)
2c. Project Address

Street Address
Address Line 2
aiy
R�stal / Zip Code
2d. Site coordinates in decimal degrees
State / FYovince / F�gion
Country
Please collect site coordinates in decimal degrees. Use bet�en 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.)
Latitude:* Longitude:*
35.35743 -77.84644
ex:34.208504 -77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
West Bear Creek
3b. Water Resources Classification of nearest receiving water:*
C;Sw, NSW
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Neuse
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 with some rural single-family residential housing in the
vicinity of this project.
4b. Attach an 8 7/2 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
Wayne 15 topo map.pdf 1.69M6
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
Wayne 15 soils 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:
(interrritterd and perennial)
100
4f. Explain the purpose of the proposed project:*
Replace e�asting Bridge 15 which is structurally deficient for current NCDOT standards.
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4g. Describe the overall project in detail, including indirect imapacts and the type of equipment to be used:*
Replace e�asting Bridge 15 which is structurally deficient for current NCDOT standards with a new bridge meeting
these current standards in the epsting right-of-way. Heavy road and bridge building equipment will be used.

4h. Please upload project drawings for the proposed project.
Qick the upload button or drag and drop files here to attach docurrent
950015 Permit Drawings.pdf 3.46M6
Fle type rrust be pdf
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or proposed impact areas?*
G Yes C' No �' Unknown
Comme nts:
5b. If the Corps made a jurisdictional determination, what type of determination was made?*
f' Preliminary �' Approved C•' Unknown f' f�UA
Corps AID Number:
6carrple:SAW-2017-99999
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Othe r:
Chad Coggins
NCDOT
5d. 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 FCF
6. Project History
6a. Have permits or certifications been requested or obtained for this project (including all prior phases) in the past? *
l' Yes C No C' 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 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 Impacts Inventory
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
r Wetlands �J Streams-tributaries �J 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
impacted.

3a. Reason for impact*3b.lmpact 3c. Type of impact*3d. Stream name *
type *
S1 Bridge construction T Dewatering West Bear Creek
dewatering F�rrranent(�jor
N�p label (e.g. fd�ad Qossing 1) Terrporary (�
g2 Bridge bank P Bank West Bear Creek
stabilization F2rrranent(Fjor Stabilization
Nfip label (e.g. Fd�ad Q'ossing 1) Terrporary (�
3e. Stream 3f. Type of 3g. Stream 3h. Impact sqfe�
Type� Jurisdiction* width* length*
Perennial Both 16 20 3
F�rennial (�) or Average (feet) (linear feet) 2
interrrittent (IfVn 0
Perennial Both 16 87 1
F2rennial (Fff2) or Average (feet) (linear feet) ,
interrrittent (IMj 3
9
2
�" 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:
87
3i. Total temporary stream impacts:
20
3i. Total stream and tributary impacts:
107
3j. Comments:
6. Buffer Impacts (for DWR)
If project will impact a protected riparian buffer, then complete the chart below. Individually list all buffer impacts below.
6a. Project is in which protect basin(s)?*
Check all that apply.
fJ Neuse r Tar-Pamlico
r Catawba r Randleman
r Goose Creek r Jordan Lake
r Other
6b. Impact Type *
Bridge approaches allowable
Location and 6cerrpt, Allowable, allowable w/
rritigation
6h. Total buffer impacts:
Temporary impacts:
Permanent impacts:
Total buffer impacts:
6i. Comments:
6c. Per or
Temp*
P
F�rrranent (Pj or
Terrporary (�
Zone 1
0.00
Zone 1
6,400.00
Zone 1
6,400.00
6d. Stream name *
West Bear Creek
Zone 2
0.00
Zone 2
3,511.00
Zone 2
3,511.00
6e. Buffer mitigation
required?*
No
6f. Zone 1
impact *
6,400
(squarefeet)
6g. Zone 2
impact*
3,517
(square feet)

Supporting Documentation - i.e. Impact Maps, Plan Sheet, etc.
aick the upload button or drag and drop files here to attach docurrent
950015 Permit Drawings.pdf 3.46MB
Fle rrust be FDF
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:*
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 the project. Safety fencing will be used to delineate jurisdictional and
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?
f Yes r No
2b. If this project DOES NOT require Compensatory Mitigation, explain why:
Below thresholds of significant jurisdictional impacts.
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
1b. All buffer impacts and high ground impacts require diffuse flow or other form of stormwater treatment. If the project is subject to a
state implemented riparian buffer protection program, include a plan that fully documents how diffuse flow will be maintained.
All Stormwater Control Measures (SCM)s must be designed in accordance with the NC Stormwater Design Manual. Associated
supplement forms and other documentation shall be provided.
What type of SCM are you providing?
r Level Spreader
rJ Vegetated Conveyance (lower SMNT)
� Wetland Swale (higher SMNT)
r Other SCM that removes minimum 30% nitrogen
(check all that apply)
For a list of options to meet the diffuse flow requirements, click here.
Diffus Flow Documentation
C7ick the upload button or drag and drop files here to attach docurrent
950015_HYD_SMPv2.07_(Oct 2016).pdf 265.98KB
Fle type rrust be FDF
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250? *
f• Yes r 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)?*
f Yes �' No
Comme nts: *
MCDC available on 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)?*
l' Yes r No
2b. Is this an after-the-fact permit application?*
f 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 b' No
3b. If you answered "no," provide a short narrative description.
Replacing exsting 2 lane bridge with new2 lane bridge.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?*
f 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 �' No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
C' Yes C•' No
5d. Is another Federal agency involved?*
f Yes C No
5e. Is this a DOT project located within Division's 1-8?*
C•' Yes r No
r Unknown
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat? *
Freshwater Mussel Survey Report conducted by NCDOT EAU, Biological Surveys Group (Matt Haney) dated
January 12, 2017, with conclusion of NO AFFECT for Yellow Lance. Programmatic BO of MA/LTAA for NLEB.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*

r Yes r No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat? *
G IS
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 r 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
C7ick the upload button or drag and drop files here to attach docurrent
17-08-0007NoSurveyReq.pdf
PA 17-08-0007 Wayne (NSR).pdf
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?*
f• Yes �' No
8b. If yes, explain how project meets FEMArequirements:
MOA
8c. What source(s) did you use to make the floodplain determination?*
F RIS
Miscellaneous
Miscellaneous attachments not previously requested.
C7ick the upload button or drag and drop files here to attach docurrent
17BP.4.R.87 mussel report.pdf
Fle rrust be FDF or 4WQ
Signature
fJ By checking the box and signing below, I certify that:
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7.56MB
738.1 KB
■ 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

Clr��C' o�r�rr��
Initial Review
Is this project a public transportation project?* (?)
f• Yes r No
Change only if needed.
Has this project met the requirements for acceptance in to the review process? *
f• Yes
f No
BIMS # Assigned *
20180401
Version#*
Reviewing Office *
Central Office - [phone]
Select Project Reviewer*
Rob Ridings:eads\rgridings
Is a payment required for this project?*
l' No payment required
G Fee received
C' Fee needed - send electronic notification