20180544 Ver 1_401 Application_20180418

DWR
Division of 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 able to submit the form until all mandatory questions are answered.
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.govMaterResources/0/edocl6247041PCN%20Help%20File%202018-1-30.pdf
A. Processing Information
County (or Counties) where the project is located:*
Forsyth
Is this project a public transportation project?*
f Yes f• No
This is any publicly funded by nunicipal,state or federal funds road, rail, airport transportation project.
1a. Type (s) of approval sought from the Corps:*
V Section 404 Permit (wetlands, streams and waters, Clean Water Act)
F Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
1b. What type(s) of permit(s) do you wish to seek authorization?*
IJ 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: 27 - Restoration
NWP Number Other:
List all IWV nurrbers you are applying for not on the drop down list.
1c. Type(s) of approval sought from the DWR:*
check all that apply
IJ 401 Water Quality Certification - Regular r 401 Water Quality Certification - Express
F Non -404 Jurisdictional General Permit r Riparian Buffer Authorization
r Individual Permit
*
1d. Is this notification solely for the record because written approval is not required?
For the record only for DWR 401 Certification:
O Yes O No
For the record only for Corps Permit: O Yes O 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 mitigation bank or in -lieu fee program
f Yes C No
1f. Is the project located in anyof NC's twentycoastal counties?*
r Yes C No
1h. Is the project located in a designated trout watershed?*
f Yes f• No
Link to trout information: http://vmw.saw.usace.army.mil/Missions/Regulatory-Permit-ProgranVAgency-Coordination/Trout.aspx
B. Applicant Information
1a. Who is the Primary Contact?*
Amy Black
1b. Primary Contact Email:*
[e-mail]
1c. Primary Contact Phone:*
(XXX)XXX-XXXX
[phone]
1d. Who is applying for the permit?
❑ owner rJ Applicant (other than owner) rJ Agent/Consultant
(Check all that apply)
2. Owner Information
2a. Name(s) on recorded deed:
Jessie G. Taylor
2b. Deed book and page no.:
Not listed in public records
2c. Responsible party:
(for Corporations)
2d. Address
Street Address
4146 N. Patterson Ave
Address Line 2
City
Winston Salem
Rbstal / Zip Code
27105
2e. Telephone Number:
(XXX)XXX-XXXX
2f. Fax Number:
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
3. Applicant Information (if different from owner)
3a. Applicant is:
State/ Province/ Fbgion
NC
Country
USA

O Agent
f• Other City of Winston Salem - by easement
If other please specify.
3b. Name:
Courtney Driver, PE
3c. Business Name:
(if applicable)
3d. Address
Street Address
PO Box 2511
Address Line 2
CSty
State / Province / Fbgion
Winston Salem
NC
Postal / Zip (ode
Country
27102
USA
3e. Telephone Number:
[phone]
(xxx)xxx-xxxx
3f. Fax Number:
(xxx)xxx-xxxx
3g. Email Address:*
[e-mail]
4. Agent/Consultant (if applicable)
4a. Name:
Amy Black
4b. Business Name:
ff applicable)
JEWELL Engineering Consultants, PC
4c. Address
Street Address
311-A South Main Stret
Address Une 2
aty
State / Province / Region
Kernersville
NC
Fbstal / Zip Code
Country
27284
USA
4d. Telephone Number:
[phone]
(xxx)xxx-xxxx
4e. Fax Number:
(XXX)XXX-)O=
4f. Email Address:*
[e-mail]
Agent Authorization Letter*
Please provide the Agent Authorization Letter if you are subrritting this docurrent.
Signed Agent Authorization Form.pdf 79.43KB
PlLE IYFE MJST BE FDF

C. Project Information and Prior Project History
1. Project Information
..................................................................................................................................................................................................................................................................................................................................................................................................................................
1a. Name of project..*
Site 5 - CCUC Sewer Crossing Stabilization
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/ town:*
Winston Salem
1d. Driving directions*
If it is a new project and can not easily be found in a CPS napping system Please provide directions.
Tributary flows between 4146 N. Patterson Ave and adjacent motel. Site is at back of property before tributary flows into main stream.
2. Project Identification
2a. Property Identification Number:
(tax RN or parcel ID)
6828-81-2124
2b. Property size:
(in acres)
2c. Project Address
Street Address
Address Line 2
City
Pbstal / Zip Code
State / Province / Fbgion
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 how the 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:*
36.16453 -80.25982
ex: 34.208504 -77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
Leak Fork Creek
3b. Water Resources Classification of nearest receiving water:*
C
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Yadkin-PeeDee
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:*
Site 5 of the CCUC project is located on a tributary to Leak Fork Creek, which is a perennial tributary to Mill Creek.
The tributary flow is generally from east to west, with the confluence with Leak Fork Creek just downstream of the
project area.
The drainage area is approximately 0. 17 square miles of mostly industrial/commercial land use. The sanitary
sewer crossing is exposed above the channel bottom and causing erosion.
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)
Click the upload button or drag and drop files here to attach docurrent
Site 5 - USGS.pdf 9.48MB
File type mist 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)
Click the upload button or drag and drop files here to attach docurrent
Site 5 - soils.pdf 1.71 MB
File 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:
(intern ittent and perennial)
406 (delineated)
4f. Explain the purpose of the proposed project:*
This project is proposed to address erosion of the stream channel that is exposing and threatening utilities
(sanitary sewer). Through the use of natural channel concepts, the streambank will be stabilized to halt the
erosion and protect the utility infrastructure.
4g. Describe the overall project in detail, including indirect imapacts and the type of equipment to be used:*
This project will raise the channel elevation at the utility crossing approximately 6 inches above the sewer pipe with
a constructed riffle. A downstream grade control drop structure of boulder steps will be built to meet existing
channel grade before the stream converges with Leak Fork Creek. The sanitary sewer pipe under the stream bed
will remain in place, but a portion of the pipe in the stream bank will be replaced with ductile iron pipe.
4h. Please upload project drawings for the proposed project.
Click the upload button or drag and drop files here to attach docurrent
Site 5 - Project Drawings.pdf 826.67KB
File type mist be pdf
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or proposed impact areas?*
f• Yes r No r Unknown
Comments:
Delineated, but not requested
5b. If the Corps made a jurisdictional determination, what type of determination was made?*
r Preliminary r Approved r Unknown C N/A
Corps AID Number:
Exarrple: SAW -2017-99999
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Other:
Valarie Cowden
Briarpatch Ecology & Design Works, LLLC

5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5d1. Jurisdictional determination upload
Qick the upload button or drag and drop files here to attach docurrent
File type mist be FDF
6. Project History
6a. Have permits or certifications been requested or obtained for this project (including all prior phases) in the past?
r Yes G No b Unknown
7. Future Project Plans
7a. Is this a phased project?*
C Yes C 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):
F- Wetlands V Streams -tributaries ❑ Buffers
❑ Open Waters ❑ 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 * 3e. Stream 3f. Type of 3g. Stream 3h. Impact
type * Type * Jurisdiction * width * length
S1 Stream B - T Stabilization Unnamed Trib Perennial Both 3 88
Stabilization F2rrranent (P) or Perennial (FHS or Average (linear feet)
Nbp label (e.g. Road Qossing Tenporary (T) internittent (INT) (feet)
1)
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:
0
3i. Total temporary stream impacts:
88
3i. Total stream and tributary impacts:
88
3j. Comments:
All proposed impacts are temporary and are related to streambank stabilization, habitat enhancement, and
restoration. Stream impacts are referenced to delineated streams on Figure 8 in attached WOUS report.
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:*
All proposed impacts to jurisdictional stream channels are related to stabilizing eroding streambanks and restoring
habitat. Multiple engineering alternatives were considered, including hardened bank structures, but natural
channel design parameters were selected to most effectively accomplish project goals.
Work in the stream will be done will be done in dry conditions. Pump around operations will be used, if needed
The project proposes no impacts to jurisdictional wetlands.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
An Erosion and Sediment Control permit will be acquired for this project and appropriate erosion and sediment
control measures will be implemented.
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:
Impacts are temporary
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?
r Yes r 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?
r Yes r No
2b. Does this project meet the requirements for low density projects as defined in 15A NCAC 02H .1003(2)?*
r Yes
r No
To look up low density requirement click here 15A NCAC 02H.1003(2)
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?
6 Yes r 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 Policy Act (NEPA/SEPA)?*
r Yes r No
Comments: *

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?*
f Yes r 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?*
f Yes r No
3b. If you answered "no," provide a short narrative description.
The project will not contribute impervious surface to the watershed.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?*
f Yes r Nor N/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?
f Yes r No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
r Yes r No
5c. If yes, indicate the USFWS Field Office you have contacted.
Asheville
5d. Is another Federal agency involved?*
f Yes r No r Unknown
5e. Is this a DOT project located within Division's 1-8?*
f Yes r No
5f. Will you cut any trees in order to conduct the work in waters of the U.S.?
r Yes r No
5g. Does this project involve bridge maintenance or removal?
f Yes r No
Link to the NLEB SLOPES document: http://saw-reg.usace.army.mil/NLEB/1-30-17-signed_NLEB-SLOPES&apps.pdf
5h. Does this project involve the construction/installation of a wind turbine(s)?*
r Yes r 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?
Created an iPaC report (https://ecos.fws.gov/ipac/). Also spoke with Byron Hamstead in Fish & Wildlife Asheville
Field Office on 03/01/2018. Confirmed no impact.

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?*
NOAA Essential Fish Habitat Mapper (http://wmty.habitat.noaa.gov/protection/efh/efhmapper/indexhtmi)
Confirmed with Byron Hamstead in Fish & Wildlife Asheville Field Office on 3/1/2018.
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)?*
r Yes r No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?*
Used the spatial data from National Register of Historic Places from nps.gov website
7c. Historic or Prehistoric Information Upload
Click the upload button or drag and drop files here to attach docurrent
File must 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 FEMXdesignated 100 -year floodplain?*
r Yes r No
8b. If yes, explain how project meets FEMA requirements:
No -Rise Certification will be submitted to City of Winston-SalerTVForsyth County Floodplain Administrator.
8c. What source(s) did you use to make the floodplain determination?*
Flood Risk Information System (http://www.fris.nc.gov) and best engineering practices.
Miscellaneous
Miscellaneous attachments not previously requested.
Click the upload button or drag and drop files here to attach document
WOUS Report Site 5 - 4170 N Patterson Ave.pdf 25.44MB
Site5_Fig1_Topo.pdf 253.76KB
Site 5 Project Narrative.pdf 433.47KB
File must be FDF or KW
Signature
V 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 Act');
■ I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic
Transactions Act');
■ 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 Black, PE
Signature
Initial Review
.......... .................. .................. ........................................................................
Is this project a public transportation project?* (?
0 Yes f• No
Change only if needed.
Has this project met the requirements for acceptance in to the review process?*
f• Yes
f No
BIMS # Assigned*
20180544
Version#*
Reviewing Office*
Winston-Salem Regional Office - [phone]
Select Project Reviewer*
Sue Homewood:eads\slhomemod
Is a payment required for this project?*
f No payment required
f Fee received
r Fee needed - send electronic notification
What amout is owed?*
r $240.00
O $570.00