20181195 Ver 1_PCN Form Submission_20180829

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 8/29/2018 12:46:23 PM (Start Event)
Accept by Carpenter,Kristi 8/29/2018 7:08:20 PM (DOT Initial Review)
. The task was assigned to Carpenter,Kristi. The due date is: September 3, 2018 5:00 PM
8/29/2018 12:48 PM

�� �
�ivislan af Water Resour�es
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:*
Davidson
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.9. R.61
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:
Nationwide Permit (NWP) Number:
Nationwide Permit (NWP) Number
03 - Maintenance
73 - Bank Stabilization
12 - Utility Lines
NWP Number Other:
List all MN nurrbers you are applying for not on the drop dow n 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:
For the record onlyfor Corps Permit:
f Yes C' No
f' Yes C' 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 — NCDOT Div 9 EO
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:
NCDOT Division 9
2b. Deed book and page no.:
2c. Responsible party:
(for Corporations)
2d. Address
Street Address
375 Silas Creek Parkway
Address Line 2
aty
Winston-Salem
Fbstal / Zip Code
27127
2e. Telephone Number:
(xxx)xxx-xxxx
[phone]
State / FYovince / F�gion
NC
Caurdry
USA

2f. Fax Number:
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
3. Applicant Information (if different from owner)
3a. Applicant is:
f Agent
f' Other
IF other please spec'rfy.
3b. Name:
3c. Business Name:
(if applicable)
3d. Address
Street Adaress
Address Line 2
a�y
Fbstal / Zip Code
3e. Telephone Number:
(xxx)xxx-xxxx
3f. Fax Number:
(xxx)xxx-xxxx
3g. Email Address:*
[e-mail]
State / Rrnince / F�gion
Country
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
Replacement of Bridge #280410 on SR 1844 over Leonard Creek
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:*
Lexingtan, NC
1d. Driving directions*
IF it is a new project and can not easily be found in a GPS rrapping system Rease provide directions.
From Le�angton take SR 1844(Greensboro Street) north for appro�amately two miles to Bridge #280410 over Leonard Creek.
2. Project Identification
2a. Propertyldentification Number:
(tax RN or parcel ID)
2b. Propertysize:
(in acres)

2c. Project Address
Street Address
Address Line 2
a�y
Fbstal / Zip Code
2d. Site coordinates in decimal degrees
State / FYovince / F�gion
Country
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 e�cample, 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:*
35.842028 -80.222296
ex: 34208504 -77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:�
Leonard 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:*
E�sting Conditions include SR 1844 and Bridge #280410, residential, agricultural, commercial, undeveloped forest
and disturbed/maintained right-of-way.
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)
Click the upload button or drag and drop files here to attach docurrent
USGS_Davidson_Div9_Bridge410.pdf 1.41 MB
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)
Qick the upload button or drag and drop files here to attach docurrent
Soils_Davidson_Div9_Bridge410.pdf 3.09MB
Fle type rrust be pdF
4d. List the total estimated acreage of all existing wetlands on the property:
0.27
4e. List the total estimated linear feet of all existing streams on the property:
(interrrittent and perennial)
250
4f. Explain the purpose of the proposed project:*
To improve Bridge #280410 and replace with a new, modern bridge structure.
4g. Describe the overall project in detail, including indirect impacts and the type of equipment to be used:*

Bridge construction using heavy construction equipment. The proposed bridge will be built on the same alignment
with a temporary off-site detour.
4h. Please upload project drawings for the proposed project.
Qick the upload button or drag and drop files here to attach docurrem
bridge 280410-S028 Permit Drawings rev.pdf
Fle type rrust be pdf
5. Jurisdictional Determinations
2.06MB
5a. Have the wetlands or streams been delineated on the property or proposed impact areas? *
C Yes C' No �' Unknown
Comme nts:
5b. If the Corps made a jurisdictional determination, what type of determination was made?*
f' Preliminary �' Approved C' Unknown
Corps AID Number:
6carrple: SAV�2017-99999
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Othe r:
Sam Beavens
Mulkey
f� f�UA
5d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5d7. Jurisdictional determination upload
Qick the upload button or drag and drop files here to attach docurrent
Bridge280410_NCDWQ Wetland Rating_20130410.pdf
Bridge280410_SA NCDWQ Stream.pdf
Bridge280410_SA_USACE Stream_20130710.pdf
Bridge280410_WA_USACE Upland Piedmont.pdf
Bridge280410_WA_USACE Wetland Piedmont Template.pdf
20141212_Bridge280410_Fig1.pdf
20141212_Bridge280410_F ig 2. pdf
20141212_Bridge280410_F ig3. pdf
Fle type rrust be FDF
6. Project History
768.48KB
690.63KB
1.37MB
9.66MB
9.65MB
1.07MB
500.24KB
1.15MB
6a. Have permits or certifications been requested or obtained for this project (including all prior phases) in the past? *
l' Yes C No C' Unknown
7. Future Project Plans
7a. Is this a phased project?*
f 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):
rJ Wetlands �J Streams-tributaries r Buffers
r 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*
W1 - wetland fill P Bottomland Hardwood
N�p label (e.g. Fd�ad Qossing 1- Qalvert, F2rrranent (� or FOfest
dewatering, etc) Terrporary (�
W2 - mechanized clearing P Bottomland Hardwood
N�p label (e.g. Fd�ad C7ossing 1- Qalvert, �rrranent (Pj or ForeSt
dewatering, etc) Terrporary (�
2g. Total Temporary Wetland Impact
0.000
2g. Total Permanent Wetland Impact
0.090
2g. Total Wetland Impact
0.090
2d. Wetland name *2e. 2f. Type of 2g. Impact
Forested* Jurisdicition* area*
Wetland A Yes Both 0.010
(404, 10) or D✓VR(401, (acres)
other)
Wetland A Yes Both 0.080
(404, 10) or [7✓�ft(401, (acres)
other)
2h. Comments:
Wetland impacts include stabilization fill around the bridge abutments and the mechanized clearing of wetland
vegetation for utility line relocation.
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 *
type *
S1 Bank stabilization P Bank
Nbp label (e.g. I�ad Qossing F2rrranerd (Fj or Stabilization
1) Terrporary (�
Leonard Creek
3e. Stream 3f. Type of
Type* Jurisdiction*
Perennial Both
F2rennial (Fffl) or
interrrittent (IfVn
g2 Utility line relocation T Dewatering Leonard Creek Perennial Both
N�p label (e.g. Fd�ad Qossing F2rrranent (Fj or F2rennial (� or
1) Terrporary (lj ir�terrrittent (If�
*� 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:
179
3i. Total temporary stream impacts:
34
3i. Total stream and tributary impacts:
213
3g. Stream 3h. Impact sqfe�
width * length *
15 179 2
Average (linearfeet) ,
(feet) 6
8
5
15 34 5
Average (linearfeet) 7
(feet) 0

3j. Comments:
Temporary impacts are associated with the dewatering required for the crossing of the relocated utility lines. The
open cut area will be restored to original contours upon completion. Permanent impacts will result from the bank
stabilization.
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:*
Replace bridge in-place was incorporated to minimize impacts. The bridge span length was extended to reduce
impacts. Riprap at the embankments is minimized to reduce impacts to surface waters.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
NCDOT Best Management Practices (BMPs) for Construction and Maintenance Activities will be employed. Top
down demolition and construction methods will be used to minimize impacts.
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
2b. If this project DOES NOT require Compensatory Mitigation, explain why:
Wetland impacts are belowthe 0.10 acre threshold, and bank stabilization is not a loss of water and thus non-mitigable.
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?
f Yes r No
For a list of options to meet the diffuse flow requirements, click here.
If no, explain why:
Project is located in the Yadkin-Pee Dee River Basin
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250? *
C Yes r 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 �' 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)?*
l' Yes r No
Comme nts: *
A State Minimum Criteria Checklist 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 (75A NCAC 2B .0200)?*
f Yes r No
2b. Is this an after-the-fact permit application?*
l' Yes C•' No
3. Cumulative Impacts (DWR Requirement)
3a. Will this project (based on past and reasonablyanticipated future impacts) result in additional development, which could impact
nearby downstream water quality?*
f Yes �' No
3b. If you answered "no," provide a short narrative description.
Project involves the replacement of an ewsting bridge and is not anticipated to affect future development.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?*
C' Yes C' No C•' rUA
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 C' No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
f• Yes �' No
5c. If yes, indicate the USFWS Field Office you have contacted.
Asheville
5d. Is another Federal agency involved?*
f Yes C No
5e. Is this a DOT project located within Division's 1-8?*
C' Yes C•' No
5f. Will you cut any trees in order to conduct the work in waters of the U.S.?
C•' Yes f No
5g. Does this project involve bridge maintenance or removal?
G' Yes r No
l" Unknown
5g(1). 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.
C•' Yes f 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(1), did you discover anysigns of bat use?*
C' Yes C•' No C' 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(s)?*
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.?
f Yes r No
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
NCNHP data and site specific surveys.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
C' Yes r No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat? *
NOAA EFH mapper
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)?*
f Yes b' No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?'�
See attached "No Survey Required" determinations.
7c. Historic or Prehistoric Information Upload
C7ick the upload button or drag and drop files here to attach docurrent
280410 No Surveyform.pdf 1.11MB
280410 NoSurvey.pdf 1.98MB
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 l" No
8b. If yes, explain how project meets FEMArequirements:
NCDOT Hydraulics Unit Coordination with FEMA.
8c. What source(s) did you use to make the floodplain determination?*
FEMA FIRM maps
Miscellaneous
Miscellaneous attachments not previously requested.
aick the upload button or drag and drop files here to attach docurrent
Brg 280410 Permit Cover Letter signed.pdf 47.7KB
Fle rrust be FDF or VWQ
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
%�1%fCjrdlc�
Date Submitted:
8/29/2018
Initial Review
Is this project a public transportation project?* (')
r Yes f' No
Change only 'rf needed.
Has this project met the requirements for acceptance in to the review process? *
l•' Yes
C' No
BIMS # Assigned �`
20181195
Version#*
Reviewing Office *
Winston-Salem Regional Office - [phone]
Select Project Reviewer*
Dave Wanucha:eads\djwanucha
Is a payment required for this project?*
f No payment required
C Fee received
f Fee needed - send electronic notification