20180087 Ver 2_PCN Application_20180420

DWR
Dfutston 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.gov/WaterResources/0/edoc/624704/PCN%20Help%20File%202018-1-30. pdf
A. Processing Information
County (or Counties) where the project is located:*
Davie
Is this project a public transportation project?*
r Yes G No
This is any publicly funded by rrunicipal,state or federal funds road, rail, airport transportation project.
1a. Type(s) of approval sought from the Corps:*
PF 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?*
r% 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: 12 - Utility Lines
NWP Number Other:
List all WV nun-bers you are applying for not on the drop dow n list.
1c. Type(s) of approval sought from the DWR:*
check all that apply
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 only for DWR 401 Certification:
For the record only for Corps Permit:
b Yes b No
O Yes a No
1e. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
V so, attach the acceptance letter from mitigation bank or in -lieu fee program
b Yes O No
Acceptance Letter Attachment
Click the upload button or drag and drop files here to attach document
RLETYFE M -ST BE FDF
1f. Is the project located in any of NC's twenty coastal counties?*
r Yes r No
1h. Is the project located in a designated trout watershed?*
r Yes r No
Link to trout information: http://wwvv.saw.usace.army.miI/Missions/Regulatory-Permit-Program/Agency-Coordination/Trout.aspx
B. Applicant Information
1a. Who is the Primary Contact?*
Joey Lawler
1b. Primary Contact Email:*
[e-mail]
1c. Primary Contact Phone:*
(XXX)XXX-XXXX
1d. Who is applying for the permit?
r Owner r Applicant (other than owner) r% Agent/Consultant
(Check all that apply)
2. Owner Information
2a. Name(s) on recorded deed:
See original January 16, 2018 PCN - DWR #20180087
2b. Deed book and page no.:
2c. Responsible party:
(for Corporations)
2d. Address
Street Address
Address Line 2
City
Postal / Zip Code
2e. Telephone Number:
(XXX)XXX-XXXX
Fax Number:
(XXX)XXX-XXXX
2g. Email Address:*
[e-mail]
/ Province/ Region
Country

4. Agent/Consultant (if applicable)
4a. Name:
See original January 16, 2018 PCN - DWR #20180087
4b. Business Name:
(if applicable)
4c. Address
Street Address
Address Line 2
CRY
Pbstal / Zip Code
4d. Telephone Number:
(xxx)xxx-xxxx
4e. Fax Number:
(XXX)XXX-XXXX
Email Address:*
[e-mail]
State / Province / Fbgion
Country
Agent Authorization Letter*
Rease provide the Agent Authorization Letter if you are subrritting this docurrent.
doc19023620171031141330.pdf 74.76KB
RLE TYPE M -ST BE RDF
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Clemmons Area Upgrade - DWR #20180087
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality / town:
*
Mocksville
1d. Driving directions*
V it is a new project and can not easily be found in a GPS mapping system Rease provide directions.
See original January 16, 2018 PCN - DWR #20180087
2. Project Identification
2a. Property Identification Number:
(tax RN or parcel ID)
See original January 16, 2018 PCN
2b. Property size:
(in acres)
2c. Project Address

Street Address
Address Line 2
City State / Province / Region
festal / Zip Code 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:
35.878994 -80.560372
ex: 34.208504 -77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
See original January 16, 2018 PCN - DWR #20180087
3b. Water Resources Classification of nearest receiving water:*
See original January 16, 2018 PCN - DWR #20180087
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:*
See original January 16, 2018 PCN - DWR #20180087
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)
nick the upload button or drag and drop files here to attach docurrent
File 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)
Gick the upload button or drag and drop files here to attach docurrent
File type rrust be pdf
4d. List the total estimated acreage of all existing wetlands on the property:
See original January 16, 2018 PCN - DWR #20180087
4e. List the total estimated linear feet of all existing streams on the property:
(intermttent and perennial)
See original January 16, 2018 PCN - DWR #20180087
4f. Explain the purpose of the proposed project:*
See original January 16, 2018 PCN - DWR #20180087
4g. Describe the overall project in detail, including indirect imapacts and the type of equipment to be used:
See original January 16, 2018 PCN - DWR #20180087
4h. Please upload project drawings for the proposed project.

Click the upload button or drag and drop files here to attach docurrent
File type rrust be pdf
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or proposed impact areas?*
r Yes r No r Unknown
Comments:
See original January 16, 2018 PCN - DWR #20180087
5b. If the Corps made a jurisdictional determination, what type of determination was made?
r Preliminary r Approved f Unknown r N/A
Corps AID Number:
Exarrple: SAW2017-99999
SAW -2018-00459
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Other:
5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
See original January 16, 2018 PCN - DWR #20180087
5dl. Jurisdictional determination upload
Click the upload button or drag and drop files here to attach docurrent
File type rust 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 r No r Unknown
6b. If yes, please give the DWR Certification number or the Corps Action ID (exp. SAW -0000-00000).
See original January 16, 2018 PCN - DWR #20180087 and SAW -2018-00459
Project History Upload
Click the upload button or drag and drop files here to attach docurrent
File type mast be FDF
7. Future Project Plans
7a. Is this a phased project?*
r 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.
This submission is for a request to revise an e)asting authorization (DWR
#20180087) for inclusion of proposed temporary impacts to an additional
wetland area (WY) - 0.053 acre. Sue Homewood (DWR) and Bryan Roden -
Reynolds (USACE) have been contacted and made aware of this request for
revision.
D. Proposed Impacts Inventory

1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
V Wetlands r- Streams -tributaries r- Buffers
rf Open Waters r- Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a. Site # - Reason for impact* 2b. Impact type * 2c. Type of wetland * 2d. Wetland name *2e. 2f. Type of 2g. Impact
Forested* Jurisdicition* area*
See original January 16, 2018 T Headwater Forest WY Yes Both 0.053
PCN Fbrrranent (P) or (404, 10) or DIVR(401, (acres)
Ivbp label (e.g. Fbad Crossing 1 - CLlvert, Temporary (T) other)
dewatering, etc)
2g. Total Temporary Wetland Impact
0.053
2g. Total Permanent Wetland Impact
0.000
2g. Total Wetland Impact
0.053
2h. Comments:
As currently proposed, the project will impact an additional 0.053 acre of wetland (WY) that was not accounted for
in the original PCN submittal. Sue Homewood (DWR) and Bryan Roden -Reynolds (USACE) have been contacted
and made aware of this request for revision.
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:*
See original January 16, 2018 PCN - DWR #20180087
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
See original January 16, 2018 PCN - DWR #20180087
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?
r Yes r No
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?*
r Yes r No
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)? *
r Yes r No
2b. Is this an after -the -fact permit application?*
r 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?*
r Yes r No
3b. If you answered "no," provide a short narrative description.
See original January 16, 2018 PCN - DWR #20180087
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?
r 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?*
r 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?*

r Yes r No r Unknown
5e. Is this a DOT project located within Division's 1-8?*
r 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?
r 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.?
r Yes r No
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
See original January 16, 2018 PCN - DWR #20180087
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?*
See original January 16, 2018 PCN - DWR #20180087
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?
See original January 16, 2018 PCN - DWR #20180087
7c. Historic or Prehistoric Information Upload
Click the upload button or drag and drop files here to attach docurrent
File 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?*
r Yes r No
8b. If yes, explain how project meets FEMA requirements:
See original January 16, 2018 PCN - DWR #20180087
8c. What source(s) did you use to make the floodplain determination?*
See original January 16, 2018 PCN - DWR #20180087

Miscellaneous
Miscellaneous attachments not previously requested.
Click the upload button or drag and drop files here to attach docurrent
08_AERIALrev.pdf 1.67MB
SAW201800459 Request for Revision.pdf 2.2MB
Wetlandlmpacts8X11_WY 44a.pdf 450.25KB
Wetlandlmpacts8X11 bwetlandH.pdf 439.72KB
File crust be FDF or KW
Signature
Pr 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:*
Joey Lawler
Signature
01? 06�
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?*
r Yes
r No
BIMS # Assigned *
20180087
Version#*
2
Reviewing Office*
Winston-Salem Regional Office - [phone]
Select Project Reviewer*
Sue Homewood:eads\slhomewood
Is a payment required for this project?*
r No payment required
r Fee received
r Fee needed - send electronic notification
What amout is owed? *

Q $240.00
0 $570.00