20190228 Ver 1_PCN Form Submission_20190221

D1�VR
�irlslan af Water Resources
Initial Review
Pre-Construction Notification (PCN) Form
September 29, 2018 Ver 3
Has this project met the requirements for acceptance in to the review process?*
F Yes
C' No
Is this project a public transportation project?"
� Yes r No
Change only rf needed.
BIMS # Assigned *
20190228
Is a payment required for this project?*
f No paymentrequired
� Fee received
f Fee needed - send electronic notification
Select Project Reviewer"
Dave Wanucha:eads\djwanucha
Information for Initial Review
1a. Name of project:
Replacement of Bridge No. 459 on SR 2160
1a. Who is the PrimaryContact?*
Amy Euliss
1b. PrimaryContact Email:*
[e-mail]
Date Submitted
2/21 /2019
Nearest Body of Water
UT to Hamby Creek
Basin
Yadkin-PeeDee
Water Classification
C
Site Coordinates
Latitude:
35.861
A. Processing Information
County (or Counties) where the project is located:
Davidson
Is this project a public transportation project?*
r Yes r No
Is this a NCDOT Project?*
G Yes r No
(NCDOT only) T.I.P. or state project number:
Ve rsion# *
1
Reviewing Office *
Winston-Salem Regional Office - (336) 776-
9800
1c. PrimaryContact Phone:*
[phone]
Longitude:
-80.087
::
WBS # (�)
17bp.9.r.33
1a. Type(s) of approval sought from the Corps:

rJ 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?
fJ Nationwide Permit (NWP)
r Regional General Permit (RGP)
r Standard (IP)
1c. Has the NWP or GP number been verified bythe Corps?
C' Yes r No
Nationwide Permit (NWP) Number:
14 - Linear transportation
NWP Numbers (for multiple NWPS):
1d. Type(s) of approval sought from the DWR:
fJ 401 Water Quality Certification - Regular
r' Non-404 Jurisdictional General Permit
r Individual Permit
1e. Is this notification solelyfor the record because written approval is not required?
Forthe record onlyfor DWR401 Certification:
For the record onlyfor Corps Permit:
r 401 Water Quality Certification - E�ress
r Riparian Buffer Authorization
1f. Is this an after-the-fact permit application?*
� Yes r No
1g. Is payment into a mitigation bank or in-lieu fee program proposed for mitigation of impacts?
F Yes r No
1g. Is payment into a mitigation bank or in-lieu fee program proposed for mitigation of impacts?
� Yes r No
Acceptance LetterAttachment
SR 2160 - Bridge 459 - Division 9- STR - YD 103.pdf
1h. Is the project located in any of NC's twenty coastal counties?
C' Yes r No
1j. Is the project located in a designated trout watershed?
� Yes r No
B. Applicant Information
1d. Who is applying for the permit?
rJ Owner r Applicant (other than owner)
1e. Is there an Agent/Consultant for this project?
� Yes r No
2. Owner Information
2a. Name(s) on recorded deed:
NCDOT Division 9
2b. Deed book and page no.:
2c. Responsible party:
2d. Address
Street Address
375 Silas Creek Parkway
Address Line 2
�Y
Winston Salem
Fbstal / Zip Code
27127
2e. Telephone Number:
[phone]
S[ate / FYovince I Region
NC
Cauntry
USA
2f. Fax Number:
70.07KB
x
C' Yes R No
C' Yes G No
�,

2g. Email Address:*
[e-mail]
C. Project Information and Prior Project History "
1. Project Information
1b. Subdivision name:
(rf appropriate)
1c. Nearest municipality/town:
Thomasville
2. Project Identification
2a. Propertyldentification Number:
NA
2c. Project Address
Street Address
10 Smith Ave
Address Line 2
�Y
Thomasvil le
Fbstal I Zip Code
27360
3. SurFace Waters
3a. Name of the nearest body of water to proposed project:*
UT to Hamby Creek
3b. Water Resources Classification of nearest receiving water:*
C
3c. What river basin(s) is your project located in?*
Yadkin-PeeDee
3d. Please provide the 12-digit HUC in which the project is located.
030401030204
4. Project Description and History
2b. Property size:
NA
State / Rovince I f�gion
NC
Country
USA
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:*
The e�sting conditions of the site include a road with an ewsting timber bridge over the UT to Hamby Creek in a residential area.
4b. Have Corps permits or DWR certifications been obtained for this project (including all prior phases) in the past?*
C' Yes r No C' Unknown
4d. 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)
Bridge 459 Topo map.pdf
127MB
4e. 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)
4f. List the total estimated acreage of all existing wetlands on the property:
0'
4g. List the total estimated linear feet of all existing streams on the property:
116'
4h. Explain the purpose of the proposed project:*
The project will replace the existing bridge with a new 9'X6' double barrel concrete box culvert The new culvert will have 1' sills and baffles in the lowflow culvert and 1.5' sills and
baffles in the high flow culvert. The epsting stream will be relocated on the inlet and outlet ends into a new channel with rip rap lined floodplain benches installed at the high flow barrel.
The project will also install 2 temporary pipes (87"X63") in the stream for an onsite detour to provide access to residents during construction. The temporary impacts will be restored by
sloping the stream banks back at a 2:1 or flatter, lined with coir fiber matting, and revegetated with a native riparian seed mix.
4i. Describe the overall project in detail, including indirect impacts and the type of equipment to be used:*
Standard road construction equipment �nnll be used to construct the culvert and remove the e�tisting bridge. There will be no anticipated indirect impacts.
4j. Please upload project drawings for the proposed project.
VBP.9.R.33 final permit drawings.pdf
6.73MB
5. Jurisdictional Determinations

Sa. Have the wetlands or streams been delineated on the propertyor proposed impact areas?*
r Yes r No C' Unknown
Comments:
The UT to Hamby Creek is a perennial stream. There are no other resources present in the project
footprint. No JD packet was prepared.
Sb. If the Corps made a jurisdictional determination, what type of determination was made?"
� Preliminary r Approved � Not Verified � Unknown r WA
Corps AID Number:
There is no existing AID for the project. A waters upload excel file will be emailed since an excel file
can't be attached to the application.
Sc. If 5a is yes, who delineated the jurisdictional areas?
Name (if known): Amy Euliss
P�ency/Consultant Company: NCDOT Dlvision 9
Other:
Sd1. Jurisdictional determination upload
6. Future Project Plans
6a. Is this a phased project?*
C' 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?
There are no other USACE permits to be used.
D. Proposed Impacts Inventory
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
r Wetlands IIJ Streams-tributaries r Buffers
r Open Waters I� Pond Construction
3. Stream Impacts
3i. Total jurisdictional ditch impact in square feet:
0
3i. Total permanent stream impacts: 3i. Total temporary stream impacts�,
90 26
3i. Total stream and ditch impacts:
116
3j. Comments:
The 90' of impacts for the box culverts indudes the culvert and the channel realignment necessary to align the stream with the culvert.
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:
The project utilizes floodplain benches to maintain stream width. The culvert will utilize sills to maintain bed material and reduce the chances for head
cutting. It will also be buried 1' belowthe stream bed.
1b. Specificallydescribe measures taken to avoid or minimize the proposed impacts through construction techniques:
Erosion and sedimentation BMPs will be installed prior to construction, and monitored as required by NCDOT NCS00250 permit.
�
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
2c. If yes, mitigation is required by (check all that apply):
r DWR �J Corps
2d. If yes, which mitigation option(s) will be used for this project?
r Mitigation bank rJ Payment to in-lieu fee � Permittee Responsible
program Mitigation
4. Complete if Making a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached.
r Yes �' No
4b. Stream mitigation requested:
Qinear feet)
90' at a 2:1 ratio
4d. Buffer mitigation requested (DWR only):
(square feet)
4f. Non-riparian wetland mitigation requested:
(acres)
4h. Comments
4c. If using stream mitigation, what is the stream temperature:
warm
4e. Riparian wetland mitigation requested:
(acres)
4g. Coastal (tidal) wetland mitigation requested:
(acres)
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
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?
� Yes r No
If no, explain why:
No state regulated riparian buffers are present.
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?*
r Yes r No
Comments:
See attached stormwater managemeni plan.
G. Supplementary Information
1. Environmental Documentation
1a. Does the project involve an expenditure of public (federallstate/local) funds or the use of public (federallstate) land?*
� 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 PolicyAct (NEPA/SEPA)?*
f Yes r No
Comme nts: *
meets Minimum Criteria. A MCDC 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 (15A NCAC 2B .0200)?*
� Yes r No
3. Cumulative Impacts (DWR Requirement)
3a. Will this project 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 provides no new access, thus indirect and cumulative impacts will not occur.

4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?*
C' Yes r No r WA
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
Sa. Will this project occur in or near an area with federally protected species or habitat? *
F Yes r No
Sb. Have you checked with the USFWS concerning Endangered Species Act impacts?*
f Yes r No
Sd. Is another Federal agency involved?*
f Yes r No
Se. Is this a DOT project located within Division's 1-8?
C' Yes r No
Sf. Will you cut anytrees in order to conduct the work in waters of the U.S.?
F Yes r No
Sg. Does this project involve bridge maintenance or removal?
r Yes r No
Sg(1). If yes, have you inspected the bridge for signs of bat use such as staining, guano, bats, etc.?
� Yes r No
If you answered "Yes" to 5g(1), did you discover any signs of bat use?
C' Yes r No C' Unknown
Sh. Does this project involve the construction/installation of a wind turbine(s)?*
� Yes r No
r Unknown
Si. Does this project involve (7) blasting, and/or (2) other percussive activities that will be conducted by machines, such as jackhammers, mechanized pile drivers, etc.?
r Yes r No
If yes, please provide details to include type of percussive activity, purpose, duration, and specific location of this activity on the property.
S. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
USFWS county locator website
Consultation Documentation Upload
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? *
NC Natural Heritage site
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
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?*
C' Yes r No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?*
The project was reviewed by NCDOT Cultural Resource staff for Archeological and Historic Architectural resources. No survey required forms are
attached.
7c. Historic or Prehistoric Information Upload
17-05-0003_NoSu rveyReq. pdf 4.44 MB
Structure 280459 Davidson No Archaeological Survey Required Form.pdf 1.38MB
8. Flood Zone Designation (Corps Requirement)
Sa. Will this project occur in a FEMA-designated 100-year floodplain?"
� Yes r No
Sb. If yes, explain how project meets FEMA requirements:
The project has a limited study area and meets DOTs MOA with FEMA.
Sc. What source(s) did you use to make the floodplain determination?"
NC OneMap and NCDOT culvert survey report

Miscellaneous
Comments
Miscellaneous attachments not previouslyrequested.
Smith Ave cover letter.pdf
178.01 KB
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 AcP');
• 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
(/r rT�f [jldl ircf
Date
2/21 /2019