20180925 Ver 1_PCN Form Submission_20180703

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 7/3/2018 4:03:14 PM (Start Event)
Accept by Carpenter,Kristi 7/6/2018 12:23:52 PM (DOT Initial Review)
. The task was assigned to Carpenter,Kristi. The due date is: July 6, 2018 5:00 PM 7/3/2018 4:04 PM

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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:*
Randolph
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:
17BP.8. R.76
WBS #
(for �ICDOT 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)
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: 14 - Linear transportation
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
fJ 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:
For the record onlyfor Corps Permit:
f Yes C' No
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
C Yes l" No
Acceptance Letter Attachment
C7ick the upload button or drag and drop files here to attach docurrent
SR 1911 - Bridge 416 Revised - Division 8- STR - Buffer - CF 03.pdf 75.54KB
F1LE lYFE MJST BE FDF
1f. Is the project located in any of NC's twenty coastal counties?'�
f Yes �' No
1h. Is the project located in a designated trout watershed?*
f Yes r No
Link to trout information: http://wvwv.saw.usace.army.mil/Missions/Regulatory-Permit-Program/Agency-Coordination/Trout.aspx
B. Applicant Information
1a. Who is the Primary Contact? *
Art C. king
1b. PrimaryContact Email:*
[e-mail]
1c. PrimaryContact Phone:�
(xxx)xxx-xxxx
[phone]
1d. Who is applying for the permit?
fJ Owner r Applicant (other than owner) r Agent/Consultant
(Check all that apply)
2. Owner I nformation
2a. Name(s) on recorded deed:
NCDOT Highway Division 8
2b. Deed book and page no.:
2c. Responsible party:
(for Corporations)
NCDOT Highway Div. 8
2d. Address

SYreet Address
Address Line 2
902 North Sandhills Blvd.
aty
P,berdeen
Fbstal / Zip Code
28315
2e. Telephone Number:
(xxx)xxx-�axx
[phone]
2f. Fax Number:
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
State / Rovince / Region
NC
Country
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Randolph Bridge 416
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/ town:*
Archdale
1d. Driving directions*
IF it is a new project and can not easily be found in a GPS rrapping system Rease provide directions.
I-85 South, exit at Hwy 311 Business Archdale exit. Right onto 311, then in approx 150 yards. right on to Ashland St. 0.5 miles to the bridge
2. Project Identification
2a. Propertyldentification Number:
(tax RN or parcel ID)
2b. Propertysize:
(in acres)
2c. Project Address
Street Address
Ashland St.
Address Line 2
aty
Archdale
Fbstal / Zip Code
2d. Site coordinates in decimal degrees
State / Rovince / Faegion
NC
Caurdry
Randolph
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 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:*

35.912474 -79.957376
ex:34.208504 -77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
Muddy Creek
3b. Water Resources Classification of nearest receiving water:*
WS-IV
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Cape Fear
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:*
Urban,residential, commercial.
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)
Qick the upload button or drag and drop files here to attach docurrem
3709_001.pdf 499.16KB
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
Randolph 416 Soil_Map.pdf
Fle type rrust be pdF
4d. List the total estimated acreage of all existing wetlands on the property:
NA
4e. List the total estimated linear feet of all existing streams on the property:
(interrrittent and perennial)
250
372.71 KB
4f. Explain the purpose of the proposed project:*
To replace a structurally deficient bridge with a modern structure (culvert) that meets current safety standards.
4g. Describe the overall project in detail, including indirect impacts and the type of equipment to be used:*
Replace the exsting bridge with a concrete box culvert in the same location. Equipment required: Dump truck,
excavator, crane, compactor, paving equipment.
4h. Please upload project drawings for the proposed project.
C7ick the upload button or drag and drop files here to attach docurrent
SF750416_Permit Drawings_20180625.pdf 1.96MB
Fle type rrust be pdF
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or proposed impact areas?*
C' Yes C No !' Unknown
Comme nts:
Scoping by NCDOT staff, and the consultanting firm, determined that there
are no wetlands present within the project footprint.
5b. If the Corps made a jurisdictional determination, what type of determination was made?*

f Preliminary
Corps AID Number:
6carrple: SAV�2017-99999
r Approved
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Othe r:
C' Unknown
f•' f�llA
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
Fle type rrust be FDF
6. Project History
6a. Have permits or certifications been requested or obtained for this project (including all prior phases) in the past? *
f Yes C No l" Unknown
7. Future Project Plans
7a. Is this a phased project?*
l' 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 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 r% Streams-tributaries �7 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 * 3e. Stream 3f. Type of 3g. Stream 3h. Impact sqfe�
type * Type * Jurisdiction * width * length *
S1 culvertconstruction P Fill UTofMuddyCreek Perennial Both 72 47 5
N�p label (e.g. Fd�ad Qossing F2rrranem (Fj or F�rennial (F� or Average (linear feet) 6
1) Terrporary (� interrrittent (IfVn (feet) 4
g2 bank stabilization P Bank " Perennial Both
fv�p label (e.g. f3�ad Qossing F2rrranent (P� or Stabilization F�rennial (� or
1) Terrporary (� interrritterd (If�
"" All Perennial or Intermittent streams must be verified by DWR or delegated local government.
12 99 1
Average Qinearfeet) ,
(feet) 7
8
8

3i. Total jurisdictional ditch impact in square feet:
0
3i. Total permanent stream impacts:
146
3i. Total temporary stream impacts:
0
3i. Total stream and tributary impacts:
146
3j. Comments:
Plans indicate 46.25 ft. culvert length rounded up to 47 ft. for impact mitigation.
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.
r Neuse r Tar-Pamlico
r Catawba �J Randleman
r Goose Creek r Jordan Lake
r Other
6b. Impact Type * 6c. Per or
Temp*
allowable with mitigation P
Location and 6cerrpt, Allowable, allowable w/ F2rrranent (P) or
rritigation Terrporary (�
6h. Total buffer impacts:
Temporary impacts:
Permanent impacts:
Total buffer impacts:
6i. Comments:
Zone 1
0.00
Zone 1
2,685.00
Zone 1
2,685.00
6d. Stream name *
UT of Muddy Creek
Zone 2
0.00
Zone 2
1,077.00
Zone 2
1,077.00
Supporting Documentation - i.e. Impact Maps, Plan Sheet, etc.
C7ick the upload button or drag and drop files here to attach docurrent
SF750416_Permit Drawings_BUFFER_20140108.pdf
750416 2014 SF750416 MUDDY CREEK EAST TRIB SR 1911.PDF
Fle rrust be FDF
E. Impact Justification and Mitigation
6e. Buffer mitigation
required?*
Yes
983.13KB
4.12MB
6f. Zone 1
impact*
2,685
(squarefeet)
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:*
6g. Zone 2
impact*
1,077
(square feet)

Due to the location of adjacent properties and utilities it was necessary to replace the bridge with a culvert in order
to meet the hydraulic requirements. The minimum culvert size possible to meet the hydraulic requirements and
safety standards is what is proposed.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
The stream will be de-watered and all construction work on the culvert will be done in the dry.
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?
C•' Yes C' No
2c. If yes, mitigation is required by (check all that apply):
r DWR r Corps
2d. If yes, which mitigation option(s) will be used for this project?
r Mitigation bank � 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.
r Yes
4b. Stream mitigation requested:
Qinear feet)
48
4c. If using stream mitigation, what is the stream temperature:
warm
4d. Buffer mitigation requested (DWR only):
(squarefeet)
3762
4e. Riparian wetland mitigation requested:
(acres)
NA
4f. Non-riparian wetland mitigation requested:
(acres)
NA
4g. Coastal (tidal) wetland mitigation requested:
(acres)
NA
4h. Comments
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
fJ Vegetated Conveyance (lower SHWT)
r Wetland Swale (higher SHWT)
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
Qick the upload button or drag and drop files here to attach docurrent
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? *
C Yes C' 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 �' 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 l•' No
Comme nts: *
Meets requirement for state minimum criteria.
Storm water management plan is attached to the permit drawings.
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 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 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 new structure is a minor deviation from the e�asting structure and will not change the development or land use
of the area or the adjacent properties.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?*
f Yes f No f•' 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 f" No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
f Yes �' 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 r No
C' Unknown
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
USF&W mapping data.
On site survey by NCDOT staff. Survey Checklist attached.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
l" Yes l•' No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat? *
USF&W Web data
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
reservation status e. National Historic Trust desi nation or ro erties si nificant in North Carolina histor and archaeolo *
p ( 5•, 9 p p 9 Y 9Y)�
l' Yes C•' No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources? *
SHPO review
NCDOT cultural resources review
7c. Historic or Prehistoric Information Upload
Qick the upload button or drag and drop files here to attach docurcent
13_09_0059_PA_NoSurveyReq Br 0416 on SR 1911 Asheland St over Dale Creek Div
472.43KB
08_Randolph Archaeo.pdf
13-09-0059_NoSurveyReq.pdf 2.5MB
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
8c. What source(s) did you use to make the floodplain determination?*
See Attached stormwater management plan attached to permit plan drawing.
Miscellaneous
Miscellaneous attachments not previously requested.

aick the upload button or drag and drop files here to attach docurrent
Endangered Species Survey Checklist Randolph 4161.docx.pdf 7.69K6
Justification for replacing Bridge 416 Randolph with a culvert submitted by Galen Cail
67.84KB
PE.docx.pdf
Fle rrust be FDF or 4WQ
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:*
Art C. King
Signature
�
���r.� C� C�r�'�
Date Submitted:
7/3/2018
Initial Review
Is this project a public transportation project?* (�)
C•' Yes f" No
Change only 'rf needed.
Has this project met the requirements for acceptance in to the review process? *
C•' Yes
C' No
BIMS # Assigned *
20180925
Version#*
1
Reviewing Office*
Central Office - [phone]
Select Project Reviewer*
April Norton:eads\arnorton
Is a payment required for this project?*
f No payment required
f• Fee received
f Fee needed - send electronic notification