20180512 Ver 1_PCN Form Submission_20180411

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 4/11 /2018 8:25:51 AM (Start Event)
Accept by Carpenter,Kristi 4/11/2018 10:41:16 AM (DOT Initial Review)
. The task was assigned to Carpenter,Kristi. The due date is: April 16, 2018 5:00 PM
4/11/2018 8:27 AM

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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:*
Stokes
Is this project a public transportation project?*
C Yes l' No
lhis 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 #
17BP.9. R.104
(for �ICDOT 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)
r Standard (IP)
This form may be Corps to initiate the standard/individual permit process. Please contact your Corps representative for submittal of standard permits.
All required items that are not provided in the E-PCN and be added to the miscellaneous upload located at the bottom of this form.
Nationwide Permit (NWP) Number: 13 - Bank Stabilization
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 - Express
r Non-404 Jurisdictional General Permit r Riparian Buffer Authorization
r Individual Permit
*
1d. Is this notification solelyfor the record because written approval is not required?
For the record onlyfor DWR 401 Certification: C' Yes C' 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 a- in-lieu fee program
l" Yes f' No
1f. Is the project located in anyof NC's twentycoastal counties?*
f Yes C•' No
1h. Is the project located in a designated trout watershed?*
C' Yes C No
Link to trout information: http://�wvw.saw.usace.army.mil/Missions/Regulatory-Permit-Program/Agency-Coordination/Trout.aspx
B. Applicant Information
1a. Who is the Primary Contact?*
Amy Euliss
1b. PrimaryContact Email:*
[e-mail]
1c. PrimaryContact Phone:*
(xxx)xxx-xxxx
[phone]
1d. Who is applying for the permit?
fJ Owner r7 Applicant (other than owner) r Agent/Consultant
(Checkall that apply)
2. Owner Information
2a. Name(s) on recorded deed:
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:*
State / Fhovince / I�gion
Country

[e-mail]
3. Applicant Information (if different from owner)
3a. Applicant is:
l' Agent
C' Other
If other please specrfy.
3b. Name:
3c. Business Name:
(if applicable)
3d. Address
Street Address
Address Line 2
��
Fbstal / Zip Code
3e. Telephone Number:
(xxx)xxx-xxxx
3f. Fax Number:
(xxx)xxx-xxxx
3g. Email Address:*
[e-mail]
State / Rovince / Fdegion
Caurdry
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Replacement of Bridge No. 125 on SR 1484 (Dan George Road)
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/ town:*
Danbury
1d. Driving directions*
If it is a new project and can not easily be found in a GPS rrapping system Rease provide directions.
Take NC 66 North to Moore's Spring Road. Turn L on Dan George Road. Crossing will be the second bridge on Dan George Road.
2. Project Identification
2a. Propertyldentification Number:
(tax RN or 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:*
36.432787 -80.294265
ex:34.208504 -77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
North Double Creek
3b. Water Resources Classification of nearest receiving water:*
C
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Roanoke
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:*
The surrounding area is rural residential and agriculture.
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)
aick the upload button or drag and drop files here to attach docurrent
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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)
dick the upload button or drag and drop files here to attach docurrent
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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)
approwmately 150'
4f. Explain the purpose of the proposed project:*
Replace the exsting structurally deficient bridge with a new bridge at the same location, and stabilize the bank of
the stream under the bridge.
4g. Describe the overall project in detail, including indirect imapacts and the type of equipment to be used:*
The existing bridge will be demoed according to NCDOT BMPs, and a new bridge will be constructed in the same
location. Standard road and bridge building equipment will be used.
4h. Please upload project drawings for the proposed project.

aick the upload button or drag and drop files here to attach docurrent
176P9R104_Permit Wetland_180309.pdf 1.6MB
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5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or proposed impact areas?*
G Yes r No �' Unknown
Comme nts:
The site was reviewed for jurisdictional resources, but there was only the
main crossing at Norh Double Creek present.
5b. If the Corps made a jurisdictional determination, what type of determination was made?*
C' Preliminary f Approved C' Unknown C•' f�UA
Corps AID Number:
Exarrple: SAV�2017-99999
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known): Melissa Ruiz and Pam Ferral
Agency/Consultant Company:
Othe r:
Stantec
5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
A JS determination was not requested from the USACE.
5d7. 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?*
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 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 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 * 3e. Stream 3f. Type of 3g. Stream 3h. Impact sqfei
type * Type * Jurisdiction * width * length *
g� Bank stablization P Bank North Double Creek Perennial Both 15 67 1
N�p label (e.g. Fd�ad Qossing F2rrranent (Fj or StabilizatiOn F2rennial (�) or Average (linear feet) ,
1) Terrporary (lj intermittent (If� (feet) 0
0
5
*' 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:
67
3i. Total temporary stream impacts:
0
3i. Total stream and tributary impacts:
67
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 bridge will completely span North Double Creek, and the banks will be armored for long term stability. The
erosion control plan for the project has been designed in accordance with NCDOT Design Standards in Sensitive
Watersheds.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
The placement of rip rap will be utilizing NCDOT's Best Management practice. All other work will take place outside
of the waters and sediment and erosion control measures will be implemented to isolate the wrork area.
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
2b. If this project DOES NOT require Compensatory Mitigation, explain why:
Bank stabilization impacts are not considered to be a loss of water, and thus, not a mitigable impact.
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:
NA
2. Stormwater Management Plan

2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?'�
C•' 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 C•' No
Comme nts:
*
A State MCC has been prepared.
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?*
l" Yes l•' 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 b' No
3b. If you answered "no," provide a short narrative description.
The project is a bridge replacement and does not change access to land.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?*
l" Yes C No C' f�llA
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? *
f• Yes l" No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
r Yes C' No
5c. If yes, indicate the USFWS Field Office you have contacted.
Asheville
5d. Is another Federal agency involved?*
C' Yes r No
5e. Is this a DOT project located within Division's 1-8?*
f 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
f Unknown

5g. Does this project involve bridge maintenance or removal?
G Yes r No
5g(7). 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.
G' 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(7), did you discover anysigns of bat use?*
C' Yes C•' No f 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(5)?'
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 r No
If yes, please provide details to include type of percussive activity, purpose, duration, and specific location of this activity on the
property.
C]ick the upload button or drag and drop files here to attach docurrerrt
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5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
NC Natural Heritage database and field surveys
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
f Yes r No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat? *
NA
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)?*
l•' Yes C' No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources? *
There is a National Register property adjacent to the project. See cover letter and attached effect forms for those
reviews.
7c. Historic or Prehistoric Information Upload
aick the upload button or drag and drop files here to attach docurrem
16-06-0028_EffectsSig ned. pdf
AR 16-06-0028 NoSitesAffected. 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?*
2.97MB
8.33MB

r Yes r No
8b. If yes, explain how project meets FEMArequirements:
The project has a limited detail study and an MOA with FEMA.
8c. What source(s) did you use to make the floodplain determination?*
NCDOT bridge survey report
Miscellaneous
Miscellaneous attachments not previously requested.
aick the upload button or drag and drop files here to attach docurrent
17-178 Stokes Co. Bridge 125 Replacement over N Double Creek on SR 1484 James
1.28MB
Spinymussel concurrence.pdf
176P9R104 -SMC_v2.0.pdf 12.77MB
Br 125 Dan George Rd cover letter.pdf 207.58KB
Fle rrust be F�F or INR
Signature
�7 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:*
Amy Euliss
Signature
Sign
Initial Review
Is this project a public transportation project?* (')
f• Yes r No
Change only 'rf needed.
Has this project met the requirements for acceptance in to the review process? *
f• Yes
f No
BIMS # Assigned *
20180512
Version#*
1
Reviewing Office *
Winston-Salem Regional Office - [phone]
Select Project Reviewer*
Dave Wanucha:eads\djwanucha
Is a payment required for this project?*
r No payment required
f' Fee received
f' Fee needed - send electronic notification