20181177 Ver 1_401 Application_20180823

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
Nationwide Permit (NWP) Number: 7 - Outfall Structures/ Intake
NWP Number Other:
List all MN nunbers you are applying for not on the drop down list.
1c. Type(s) of approval sought from the DWR:*
check all that apply
V 401 Water Quality Certification - Regular r 401 Water Quality Certification - Express
r Non -404 Jurisdictional General Permit r Riparian Buffer Authorization
F Individual Permit
*
1d. Is this notification solelyfor the record because written approval is not required?
For the record onlyfor DWR 401 Certification: r Yes G No

For the record only for Corps Permit:
r Yes G No
1e. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
ff so, attach the acceptance letter from n itigation bank or in -lieu fee program
f Yes IT No
1f. Is the project located in anyof NC's twenty coastal counties?*
O Yes C No
1h. Is the project located in a designated trout watershed?*
t' Yes r No
Link to trout information: http://wvvw.saw.usace.army.mil/Missions/Regulatory-Permit-ProgranVAgency-Coordination/Trout.aspx
B. Applicant Information
1a. Who is the Primary Contact?*
Keven Arrance
1b. Primary Contact Email:*
[e-mail]
1c. Primary Contact Phone:*
()XXX-XXXX
[phone]
1d. Who is applying for the permit?
V Owner r Applicant (other than owner) rJ Agent/Consultant
(Check all that appy)
2. Owner Information
2a. Name(s) on recorded deed:
City of Winston-Salem
2b. Deed book and page no.:
000711, 00425 and 000867, 00066
2c. Responsible party:
(for Corporations)
Mr. Todd Love
2d. Address
Street Address
City of Winston-Salem Stormwater Administration
Address Line 2
101 N. Main Street, Suite 53
City
Winston-Salem
Postal / Zip Code
27101
2e. Telephone Number:
(XXX)XXX-XXXX
[phone]
2f. Fax Number:
(XXX)XXX-)D=
2g. Email Address:*
[e-mail]
State / Rovince / Pegion
NC
Country
USA

4. Agent/Consultant (if applicable)
4a. Name:
Keven Arrance
4b. Business Name:
(if applicable)
Hazen and Sawyer
4c. Address
Street Address
4011 WestChase Boulevard
Address Line 2
Suite 500
qty
State / Province / Fbgion
Raleigh
NC
Postal / Zip Code
Country
27607
USA
4d. Telephone Number:
[phone]
(XXX)XXX-)O=
4e. Fax Number:
(XXX)XXX-)O=
4f. Email Address:*
[e-mail]
Agent Authorization Letter*
Rease provide the Agent Authorization Letter if you are sutxritting this docurrent.
AgentAuthorization Executed. pdf 19.42KB
RLE TYP=MHr BE RDF
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Washington Park Stream Stabilization and Retrofit
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 rrapping system Pease provide directions.
From 1-40, take exit 193C for Silas Creek Pkwy, use left two lanes to turn left onto Silas Creek Pkwy. Turn right onto Peters Creek Pkwy.
Turn right onto Link Rd. Turn left onto Hutton St. Turn right onto Washington Park Public Ln. Follow until road ends in parking lot.
2. Project Identification
2a. Property Identification Number:
(tax RN or parcel ID)
6834-09-7415 and 6834-08-4469
2b. Property size:
(in acres)
47.75

2c. Project Address
Street Address
1225 Washington Park Ln
Address Line 2
qty
State / Province / Fegion
Winston-Salem
NC
Fbstal / Zip Code
(buntry
27103
USA
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:*
36.076720 -80.250204
ex: 34.208504 -77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
Salem 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:*
Project area is contained within Washington Park, which consists of athletic fields, playground and exercise
equipment, greenway trails, and a dog play area. The majority of the park consists of maintained lawn areas with
woods surrounding the lawn areas. Salem Creek bisects the park and project area. An unnamed tributary (UT) to
Salem Creek has its beginning and confluence with Salem Creek within park property. The UT to Salem Creek has
degraded over time and is in need of repair. Current stormwater drainage from the dog park area flows over a
gravel and riprap-lined swale and through a stormwater pipe to Salem Creek. The rock -lined drainage way will be
removed and replaced by a bioretention cell. A combination of residential and commercial development surrounds
the park.
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
PCN Washington Park Topo_Vicinity.pdf 2.22MB
File type mist be pdt
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 document
PCN Washington Park Soils.pdf 1.91 MB
File type rust be pdt
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:
(intermttent and perennial)
2400
4f. Explain the purpose of the proposed project:*
The purpose of the project is (1) to improve water quality in Salem Creek, (2) to improve water quality and stream
stability in the UT to Salem Creek, and (3) to improve stormwater conveyance via the existing onsite culverts.
Runoff from dog play area discharges directly to Salem Creek untreated, negatively impacting water quality. UT to
Salem Creek is incised, degraded and continues to actively erode, which negatively impacts water quality and
threatens existing sanitary sewer and drinking water utilities. Existing greenway culvert along UT to Salem Creek is
undersized, damaged, and partially clogged preventing it from properly conveying flows.
4g. Describe the overall project in detail, including indirect impacts and the type of equipment to be used:*
This project includes two components: (1) a bioretention system in the dog park area and (2) stream restoration
and culvert replacement along the UT to Salem Creek.
The proposed bioretention work involves demolition of 160 feet of existing stormwater pipes, rip -rap and gravel,
and a section of existing asphalt path. The path section will be replaced at the end of construction. The pipe being
demolished terminates in and along the bank of Salem Creek. 410 ft of existing fence will be removed and
reinstalled in place upon completion of construction activities.
A new network of stormwater pipes and structures will be installed via open -cut trench within the project area. The
outfall of the proposed stormwater pipe will be at the same location as the existing outfall, discharging into Salem
Creek. A new reinforced concrete headwall is proposed in the same location as the existing outfall, with a final
footprint of 6 feet along the bank of Salem Creek. Proposed pipes within the bioretention area include 65 feet of 6
inch PVC, 68 feet of 10 inch HDPE, and 67 feet of 18 inch RCP. One PVC surface drain inlet, and one concrete
drop inlet will also be installed as part of the new bioretention stormwater network. Installation of the new pipe
network as well as the grading of a swale and contours in and around the proposed bioretention cell will require
equipment that will likely include, but may not be limited to, backhoes, front-end loaders, and bulldozers.
Stream stabilization work involves demolition of 30 feet of existing CMP culvert and a section of asphalt path that
will be replaced. Proposed project will involve grading of new channel dimension, pattern, and profile for UT to
Salem Creek. Existing culvert will be replaced with triple pre cast concrete box culverts. Existing exposed waterline
crossing will be protected with a poured -in-place concrete cap. Two wetland cells will be excavated above the new
culverts. Equipment that is expected to be utilized includes, but may not be limited to, backhoes, front-end loaders,
bulldozers, dump trucks, concrete mixer, and asphalt paving equipment. Temporary pump -around systems and
temporary flow diversions will be implemented during construction.
4h. Please upload project drawings for the proposed project.
nick the upload button or drag and drop files here to attach docurrent
PCN Proposed Project Drawings.pdf 18.69MB
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:
Streams were identified by a stream mitigation professional.
5b. If the Corps made a jurisdictional determination, what type of determination was made?*
r Preliminary r Approved r Unknown r N/A
Corps AID Number:
Exanple: SAM2017-99999
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.

5d1. Jurisdictional determination upload
Click the upload button or drag and drop files here to attach docurrent
File type crust 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 r 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.
No.
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 r 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 s
type* Type* Jurisdiction* width* length*
S1 Bioretention Outfall T Dewatering Salem Creek Perennial Both 60 28 1
Nbp label (e.g. Fbad Crossing F2rrrenent (F' or Perennial (PEP) or Average (linear feet) ,
1) Tenporary (T) intermittent (INT) (feet) R
S2 Bioretention Outfall P Fill
Nbp label (e.g. Finad Crossing Fern -anent (F' or
1) Terrporary (T)
S3 Stream Restoration T Dewatering
Ivbp label (e.g. Poad Crossing Permanent (F' or
1) Temporary (T)
S4 Stream Restoration P Other
Nbp label (e.g. Poad Crossing Ferrranent (F' or
1) Temporary (T)
Salem Creek Perennial Both 60 6
Perennial (FES or Average (linear feet)
intermittent (INT) (feet)
Salem Creek Perennial Both 60 52 3
Perennial (F13:� or Average (linear feet)
intermittent (INT) (feet) 1
2
0
UT to Salem Creek Perennial Both 10 541 5
Perennial (F$� or Average (linear feet)
intermittent (INT) (feet) 4
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:
547
3i. Total temporary stream impacts:

80
31. Total stream and tributary impacts:
627
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:*
Avoidance of all impacts is possible with a no -build alternative. The no -build alternative does not meet the needs
of the project and would result in continued untreated discharge of runoff from the dog play area, and continued
active erosion along UT to Salem Creek that threatens water and sewer utilities. Bioretention and stream
stabilization work has been limited to the extent necessary to ensure public safety, protect public park land and
amenities, protect public utilities, and provide water quality improvements.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
Replacement of stormwater network, outfall, headwall, and stream stabilization measures will be performed during
dry conditions. A temporary pump -around system, including a sediment trap, dewatering basin, and/or silt bag to
minimize introduction of sediment into the downstream reach of the streams, will be utilized to achieve and maintain
dry stream conditions during instream work. No live concrete will have contact with surface waters. Best
management practices in addition to sedimentation and erosion control measures will be implemented during all
phases of construction. No equipment refueling or maintenance activities will occur within or adjacent to
jurisdictional areas.
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?
C5 Yes r No
2b. If this project DOES NOT require Compensatory Mitigation, explain why:
The project impacts are below the mitigation thresholds of the Nationwide Permits that are anticipated to be utilized to authorize the
proposed work.
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
— Recent changes to the stormwater rules have required updates to this section .—
fimbli�ar"T017
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 r No
For a list of options to meet the diffuse flow requirements, click here.
If no, explain why:
The project site is not located in an area in which riparian buffers are protected by NC Riparian Buffer Protection Rules.
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?*
f• 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)?*
f Yes r No
Comments: *
Local (City of Winston-Salem) funds will be used. The proposed activities do not meet the criteria to trigger either
SEPA or NEPA review.
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.
Proposed project will cause no changes in land use and will not impact or cause any changes to surrounding land
use or land development.
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?*
f Yes r No
5d. Is another Federal agency involved?*
r Yes r No r Unknown
5e. Is this a DOT project located within Division's 1-8?*
C Yes O 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.?
r Yes r No
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
IPaC and NC Natural Heritage Program's database of element occurrences were reviewed for the project vicinity.
IPaC identified the northern long-eared bat and small-anthered bittercress as potentially occurring in the vicinity of
the project location.
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?*
NOAA online mapper of EFH
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?*
State Historic Preservation Office Historic Properties Map was reviewed on July 17, 2018. The project site is
located immediately north of the Washington Park Historic District, which is listed on the National Register of
Historic Places. No work will occur within the Historic District. Visual impacts to the character of the Historic District
will be short-term, occurring only during construction. The aesthetics of the park will be restored upon completion
of the project, with the project activities having a consistent appearance in context with the surrounding landscape.
7c. Historic or Prehistoric Information Upload
nick the upload button or drag and drop files here to attach document
HPOWEB_WashingtonPark_20180717.pdf 410.16KB
File rrust be FDF
8. Flood Zone Designation (Corps Requirement)
Link to the FEMA Floodplain Maps: https:Hmsc.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:
The proposed project will not obstruct the flow of floodwaters and will not reduce the carrying capacity of the
channel or of the floodplain. Construction activities and the site will be managed to prevent any materials or
equipment from being displaced and deposited downstream.
8c. What source(s) did you use to make the floodplain determination?*
FEMA Floodplain Map Services, FEMA NFHL
Miscellaneous
Miscellaneous attachments not previously requested.

Qick the upload button or drag and drop files here to attach docurrent
PCN Washington Park Impacts.pdf 1.45MB
File must be RDF or 109
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 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:*
Keven Arrance
Signature
C) 0/
Date Submitted:
8/23/2018
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
f No
BIMS # Assigned
20181177
Version#*
1
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
U Fee needed - send electronic notification
What amout is owed?*
f $240.00
0 $570.00

rz��rr_����:�•r:���rmit t�ir�;
PROJECT LOCATION: Washington Park
STREETADDRESS: 1225 Washington Park Ln.
Winston-Salem, NC 27103
Please print:
Applicant:
City of Winston-Salem
Applicant Contact Person: Mr. Todd Love
The undersigned applicant of the proposed project do hereby authorize
Keven Arrance
(Consultant /Agent)
of Hazen and Sawyer
(Name of Consulting Firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
the attached permit or certification and any and all standard and special conditions attached.
Applicant's Mailing Address (if different than property above):
City of Winston-Salem Stormwater/Erosion Control Division, P.O. Box 2511, Winston-Salem, NC 27102
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.

Service Layer Credits:
Figure 3: SoilsWashington Park Stream Stabilizationand RetrofitCity of Winston-SalemDepartment of Stormwater ManagementDocument Path: O:\32441-RAL\32441-000\GIS\3-MapDocuments\for permit application\Soils.mxdNOT TO SCALE
Project Location
1 inch = 2,000 feet
Service Layer Credits: Copyright:© 2013National Geographic Society, i-cubed
0 2,0001,000 Feet ®Figure 1: Project LocationWashington Park Stream Stabilizationand RetrofitCity of Winston-SalemDepartment of Stormwater Management
Project Location
Impact Site S4UT to Salem CreekPermanent Impacts to UT to Salem Creek541 Feet of Open Channel
Impact Site S1Salem CreekBioretention OutfallTemporary Impacts28 Feet of Stream
Impact Site S3Salem CreekTemporary Impact at ROP52 Feet of Open Channel
Impact Site S2Salem CreekHeadwallPermanent Impacts at Bioretention Outfall6 Feet of Stream
®Figure 2: Impact Sites 1-4Washington Park Stream Stabilizationand RetrofitCity of Winston-SalemDepartment of Stormwater ManagementDocument Path: O:\32441-RAL\32441-000\GIS\3-MapDocuments\for permit application\Impacts.mxd0 50 10025Feet
Proposed New Pipe and H eadwall
Limits of Disturbance
Unnamed Tributary to Salem Creek
Impact_Polygons
SalemCreek
Washington Park vicinity
State of North Carolina DOT, Esri, HERE, Garmin, INCREMENT P, NGA,
USGS
NR Points
NR Individual Listing
NR Listing, Gone
NRHD Center Point
NR Boundaries
National Register Boundary
Boundary of Destroyed/Removed NR Listing
SL Points
SL Individual Entry
SL and DOE entry
Study List Entry, Gone
July 18, 2018
0 0.25 0.50.13 mi
0 0.4 0.80.2 km
1:14,565