20000642 Ver 2_PCN Form Submission_20180404

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 4/2/2018 4:16:32 PM (Start Event)
Accept by Carpenter,Kristi 4/4/2018 2:05:07 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: April 5, 2018 5:00 PM 4/2/2018 4:17 PM

�� �
�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:*
Watauga
Is this project a public transportation project?*
C Yes l' No
This is any publicly funded by rrunicipal,state or federal funds road, rail, airport transportation project.
Is this a NCDOT Project?*
f• Yes r No
(NCDOT only) T.I.P. or state project number:
WBS #
11C.095123
(for f�i::DOT use only)
1a. Type(s) of approval sought from the Corps:*
fJ 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
NWP Number Other:
List all MN nurrbers you are applying for not on the drop dow n list.
74 - Linear transportation
1c. Type(s) of approval sought from the DWR:*
check all that apply
� 401 Water Quality Certification - Regular
r 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 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
C Yes l" No
Acceptance Letter Attachment
Qick the upload button or drag and drop files here to attach docurrent
Mitigation - SR 1300C - Division 11 - STR - WT 03 (cold).pdf
RLE TYFE MJST BE FDF
1f. Is the project located in anyof NC's twentycoastal counties?'�
f Yes r No
64.76KB
1h. Is the project located in a designated trout watershed?*
C•' Yes C' No
Link to trout information: http://wrwv.saw.usace.army.mil/Missions/Regulatory-Permit-Program/Agency-Coordination/Trout.aspx
B. Applicant Information
1a. Who is the Primary Contact? *
Heath Slaughter
1b. PrimaryContact Email:*
[e-mail]
1c. PrimaryContact Phone:�`
(xxx)xxx-xxxx
[phone]
1d. Who is applying for the permit?
rJ 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)
2d. Address
Street Address
801 Statesville Road
Address Line 2
a�y
North Wilkesboro
Fbstal / Zip Code
28659
2e. Telephone Number:
(xxx)xxx-xxxx
2f. Fax Number:
(�oc)xxx-xxxx
State / Rovince / f�gion
NC
Country
USA

2g. Email Address:*
[e-mail]
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
SR 1300C, Rich Mountain Road
1b. Subdivision name:
(rf appropriate)
1c. Nearest municipality/ town:*
Zionville
1d. Driving directions*
If it is a new project and can not easily be found in a GPS rrapping system Rease provide directions.
See attached map.
2. Project Identification
2a. Propertyldentification Number:
(tax RN or parcel ID)
2b. Propertysize:
(in acres)
2c. Project Address
SYreet Address
Address Line 2
a�y
Wstal / Zip Code
State / FYovince / F�gion
Country
2d. Site coordinates in decimal degrees
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:*
36.34079 -81.73575
ex:34.208504 -77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
UT to Cove Creek
3b. Water Resources Classification of nearest receiving water:*
C
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Watauga

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:*
Gravel road in a rural area.
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)
aick the upload button or drag and drop files here to attach docurrent
SR 1300C, Topo.pdf 145.29KB
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)
Qick the upload button or drag and drop files here to attach docurrent
Fle type rrust be pdF
4d. List the total estimated acreage of all existing wetlands on the property:
4e. List the total estimated linear feet of all existing streams on the property:
(interrrittent and perennial)
500
4f. Explain the purpose of the proposed project:*
Secondary Road Improvement
4g. Describe the overall project in detail, including indirect imapacts and the type of equipment to be used:*
See attached cover letter
4h. Please upload project drawings for the proposed project.
Qick the upload button or drag and drop files here to attach docurrent
SR1300C_dsn_Plans.pdf 285.18KB
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 f' No C' Unknown
Comme nts:
5b. If the Corps made a jurisdictional determination, what type of determination was made?*
C' Preliminary C' Approved C' Unknown C� 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:
Heath Slaughter
NCDOT
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 FL,F
6. Project History
6a. Have permits or certifications been requested or obtained for this project (including all prior phases) in the past?*
f Yes f•' No C' Unknown
7. Future Project Plans
7a. Is this a phased project?'�
f 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 Impacts Inventory
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
r Wetlands fJ Streams-tributaries r Buffers
r Open Waters r Pond Construction
3. Stream Impacts
ff 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 16+35 Road P Culvert
Crossing F�rrranent(P�or
N�p label (e.g. f�ad Qossing 1) Terrporary (�
g2 16+35 Road P Bank
Crossing �rrranent(Fjor Stabilization
Nfip label (e.g. Fd�ad Qossing 1) Terrporary (�
S3 16+35 Road T Dewatering
Crossing F2rrranent(F'jor
Nfip label (e.g. fmad Qossing 1) Terrporary (�
UT to Cove Creek
UTto Cove Creek
UT to Cove Creek
3e. Stream
Type'�
Perennial
F�rennial (�) or
interrrittent (IfV�
3f. Type of 3g. Stream 3h. Impact sqfe�
Jurisdiction* width* length*
Both 4 30 1
Average (feet) (linear feet) 2
Perennial Both
F2rennial (Fff2) or
interrrittent (IIVT)
Perennial Both
F�rennial (Fff2) or
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:
40
3i. Total temporary stream impacts:
40
3i. Total stream and tributary impacts:
80
3j. Comments:
E. Impact Justification and Mitigation
4 10
Average (feet) (linear feet)
4 40
Average (feet) (linear feet)
0
4
0
1
6
0

1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:*
Avoiding wetlands and widening the road away from adjacent stream.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
All appropriate BMPs will be used during construction.
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 �' No
2c. If yes, mitigation is required by (check all that apply):
r DWR r7 Corps
2d. If yes, which mitigation option(s) will be used for this project?
r Mitigation bank r% Payment to in-lieu fee program r Permittee Responsible Mitigation
4. Complete if Making a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached.
fJ Yes
4b. Stream mitigation requested:
(linear feet)
60
4c. If using stream mitigation, what is the stream temperature:
cold
4d. Buffer mitigation requested (DWR only):
(square feet)
4e. Riparian wetland mitigation requested:
(acres)
4f. Non-riparian wetland mitigation requested:
(acres)
4g. Coastal (tidal) wetland mitigation requested:
(acres)
4h. Comments
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
`"' Recent changes to the stormwater rules have required updates to this section ."`
`w•���a�r•m��Fr
1a. Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian Buffer Protection
Rules?
l' 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?*
l•' Yes f 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? *
G' 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 (NEPAISEPA)?*
f Yes r No
Comme nts: *
MCC
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?*
f Yes r No
3. Cumulative Impacts (DWR Requirement)
3a. Will this project (based on past and reasonablyanticipated future impacts) result in additional development, which could impact
nearby downstream water quality?*
f Yes f•' No
3b. If you answered "no," provide a short narrative description.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?*
l' Yes C No C' WA
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 r No
5d. Is another Federal agency involved?*
C' Yes C No
5e. Is this a DOT project located within Division's 1-8?*
f Yes C•' No
5f. Will you cut anytrees in order to conduct the work in waters of the U.S.?*
C•' Yes l' No
�' Unknown

Sg. Does this project involve bridge maintenance or removal?*
C' Yes C No
Link to the NLEB SLOPES document: http://saw-reg.usace.arrny.mil/NLEB/1-30-17-signed_NLEB-SLOPES&apps.pdf
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.?*
f Yes r No
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat? *
GIS, NHP and visual observation
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
f Yes C•' No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat? *
NOAA
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)? *
f Yes �' No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources? *
Project was reviewed by HEU.
7c. Historic or Prehistoric Information Upload
Qick the upload button or drag and drop files here to attach docurrent
17-12-0019 NoHistProps. pdf
Watauga SR 1300C No Survey form.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?*
C' Yes C•' No
8c. What source(s) did you use to make the floodplain determination?*
above link
Miscellaneous
3.43MB
1.53MB
Miscellaneous attachments not previously requested.
Qick the upload button or drag and drop files here to attach docurrent
NHP - project_report_sr_1300c_gap_section.pdf 1.95MB
SR 1300C, Letter.pdf 793.61K6
Fle rrust be FDF or IWQ
Signature

fJ 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:*
Heath Slaughter
Signature
�r`r!�f�i �l�rl�lrl�
Initial Review
Is this project a public transportation project?* (')
G' Yes f No
Change only if needed.
Has this project met the requirements for acceptance in to the review process? *
C Yes
C' No
BIMS # Assigned *
20000642
Version#*
2
Reviewing Office *
Winston-Salem Regional Office - [phone]
Select Project Reviewer*
Dave Wanucha:eads\djwanucha
Is a payment required for this project?*
f No payment required
f• Fee received
f Fee needed - send electronic notification