20190503 Ver 1_PCN Form Submission_20190417

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Pre -Construction Notification (PCN) Form
September 29, 2018 Ver 3
Initial Review
Has this project met the requirements for acceptance into the review process?*
r Yes
r No
Is this project a public transportation project?*
r Yes r No
Clarx3e only if needed.
BIMS # Assigned
20190503
Is a payment required for this project?*
r No payment required
r Fee received
r Fee needed - send electronic notification
Select Project Reviewer*
Sue Homemod:eads\slhomemod
Information for Initial Review
1a. Name of project:
Town of Kernersville Brookford Road Sanitary Sewer Extension
1a. Who is the Primary Contact?*
Mark Reich PE - Alley, Williams, Carmen & King, Inc
1 b. Primary Contact Email:*
[e-mail]
Date Submitted
4/17/2019
Nearest Body of Water
UT to West Fork Deep River
Basin
Cape Fear
Water Classification
WS- IV
Site Coordinates
Latitude:
36.087185
A. Processing Information
County (or Counties) where the project is located:
Forsyth
Is this project a public transportation project?*
r Yes r No
Longitude:
-80.057065
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 venters, tidal waters, Rivers and Harbors Act)
1 b. What type(s) of permit(s) do you wish to seek authorization?
F Nationwide Permit (NWP)
F- Regional General Permit (RGP)
P Standard (IP)
Version# *
1
Reviewing Office*
Winston-Salem Regional Office - (336) 776-
9800
1c. Primary Contact Phone:*
[phone]

1c. Has the NWP or GP number been verified by the Corps?
r Yes r No
1d. Type(s) of approval sought from the DWR:
F_ 401 Water Quality Certification - Regular r 401 Water Quality Certification - Express
F Non -404 Jurisdictional General Permit V Riparian Buffer Authorization
F Individual Permit
1e. Is this notification solely for the record because written approval is not required?
For the record only for DWR 401 Certification: r Yes r No
For the record only for Corps Permit: r Yes r No
1f. Is this an after -the -fact permit application?*
r Yes r No
1g. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
r Yes r No
1g. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
r Yes r No
Acceptance Letter Attachment
1h. lathe project located in any of NC's twenty coastal counties?
r Yes r No
1j. Is the project located in a designated trout watershed?
r Yes r No
B. Applicant Information
1d. Who is applying for the permit?
r- Owner FJ Applicant (other than owner)
1e. Is there an Age nVConsultant for this project?
r Yes (- No
2. Owner Information
2a. Name(s) on recorded deed:
Town of Kernersville - Sewer Line Easement and Eminent Domain
2b. Deed book and page no.:
2c. Responsible party:
2d. Address
Street Address
PO Box
Address Line 2
aty
Kernersville
Postal / Zip aide
27284
2e. Telephone Number:
[phone]
2g. Email Address:*
[e-mail]
3. Applicant Information (if different from owner)
3a. Name:
Curtis L. Swisher - Town Manager
3b. Business Name:
Town of Kernersville
3c. Address
State / Province / legion
NC
Q�untry
USA
2f. Fax Number:

Street Address
134 East Mountain Street
Address Line 2
PO Box 728
City
Kernersville
Postal / Zip Code
27284
3d. Telephone Number:
[phone]
3f. Email Address:*
[e-mail]
C. Project Information and Prior Project History
1. Project Information
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:
Town of Kernersville
2. Project Identification
2a. Property Identification Number:
Future Easement Current Parcel ID 6885-72-
6603,6885-82-0034,6885-71-9805
2c. Project Address
Street Address
0 Highway 66 South Hwy and 1470 Fieldmount Rd.
Address Line 2
CKY
Kernersville
Postal / Zip (ode
27284
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
UT to West Fork Deep River
3b. Water Resources Classification of nearest receiving water:*
WS- IV
3c. What river basin(s) is your project located in?*
Cape Fear
3d. Please provide the 12 -digit HUC in which the project is located.
0303000301
4. Project Description and History
State / Rovince / Iegbn
NC
Country
USA
3e. Fax Number:
[phone]
2b. Property size:
State / Rovince / Iagion
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 site North and South of 1-40 is currently wooded with a small stream flowing south . Rip rap has been placed on the stream banks within the NCDOT 1-40 controlled access
easement. General land use in the vicinity of the project North of the interstate is commercial and industrial. Land use south of the interstate is residential.
4b. Have Corps permits or DWR certifications been obtained for this project (including all prior phases) in the past?*
f Yes r No r Unknown
4d. Attach an 8 1/2 X11 excerpt from the most recent version of the USGS topographic map indicating the location of the project site. (for DWR)
USGS Map of Brookford Sewer Extension.pdf 689.06KB
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)
Highlighted Soil Map Brookford Sewer EXT.pdf 190.15KB
4f. list the total estimated acreage of all existing wetlands on the property
4g. List the total estimated linear feet of all existing streams on the property:
4h. Explain the purpose of the proposed project:*

The Town of Kernersville is planning to install a sanitary sewer main on the east side of an unnamed tributary to the West Fork tributary to Deep River east of NC Highway 66. The
project begins south of Brookford Road and will connect to the Deep River Outfall, Contract A sewer main. A 12 -inch main will be installed on the east side of the unnamed tributary
crossing under Brookford Road (SR 2604) and Fo Iiar Drive (SR 3877) up to 1-40. An 8 -inch carrier pipe will be installed through an eAsting encasement pipe under 1-40 and the line will
extend to the north to Kernersville Medical Parkway, between NC Highway 66 and Brookford Industrial Drive. The total length of the project is 3,600 If. A 430 foot section of the main was
installed by others as a part of the Kernersville Medical Parkway roadway project.
41. Describe the overall project in detail, including indirect impacts and the type of equipment to be used:*
Two locations encroach on the stream buffers one north and one south of 1-40, due to the location and access of the metal encasement pipe going under 1-40. The remainder of the
project will be 50 ft plus from the stream top of bank.
4j. Please upload project drawings for the proposed project.
Brookford Road Sanitary Sewer Extension Mapt.pdf 2.31 MB
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the propertyor proposed impact areas?*
r Yes r No r Unknown
Comments:
5b. If the Corps made a jurisdictional determination, what type of determination was made?*
r Preliminary r Approved r Not Verified r Unknown r N/A
Corps AID Number:
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Other:
5dl. Jurisdictional determination upload
6. Future Project Plans
6a. 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?
D. Proposed Impacts Inventory
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
F Wetlands r Streams -tributaries W Buffers
r Open Waters r Pond Construction
6. Buffer Impacts (for DWR)
6a. Project is in which protect basin(s)?
Check all that apply.
F Neuse r Tar -Pamlico
F Catawba V Randleman
F Goose Creek r Jordan Lake
F Other
6b. Impact Type
6c. Per or Temp
6d. Stream name 6e. Buffer mitigation required?
6f. Zone 1 impact
6g. Zone 2 impact
Buffer Zone 1 and 2
P
UT to West Fork of Deep River
Yes
1,825
3,993
6h. Total buffer impacts:
Zone 1 Zone 2
Total Temporary impacts: 0.00 0.00
Zone 1 Zone 2
Total Permanent impacts: 1,825.00 3,993.00

Zone 1 Zone 2
Total combined buffer impacts: 1,825.00 3,993.00
6i. Comments:
Supporting Documentation
10121 IMPACT DRAWING SHEET 1.pdf 162.71 KB
10121 IMPACT DRAWING SHEET 2.pdf 233.35KB
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:
All work to be done where possible out of buffer area.Only area impacted is due to eAsting encasement pipe under 1-40 in Zone 1.Sevrer alignment is
designed to minimize buffer impacts.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:
Design plans specify steps taken to avoid and 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?
r Yes r No
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 INC Riparian Buffer Protection Rules?
r Yes r No
What type of SCM are you providing?
r Level Spreader
r Vegetated Conveyance (lower SHWT)
r Wetland Swale (higher SHWT)
r Other SCM that removes minimum 30% nitrogen
rJ Proposed project will not create concentrated stormwater flowthrough the buffer
Diffuse Flow Documentation
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
Comments:
Project has 0% Impervious - Project is an utility line and will be subject to an erosion control plan.
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
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)? *
r Yes r No
Comments:*
N/A
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
3. Cumulative Impacts (DWR Requirement)
3a. Will this project 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.
Unknown, only if additional development occurs.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?*
r Yes r Nor NVA
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?*
r Yes r No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
r 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?
r Yes r No
5f. Will you cut anytrees in order to conduct the work in waters of the U.S.?
r Yes r- No
Sg. Does this project involve bridge maintenance or removal?
r Yes r No
Sh. 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.?
I- Yes r No
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
US FWS - Critical Habitat for Threatened and Endangered Species Webmap Viewer
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?*
r Yes r No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
www.fws.gov - website
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?*
r Yes r No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?*
NC Historical Preservation webmap
7c. Historic or Prehistoric Information Upload
NC Historical Pres. Map Brookford Sewer Extension.pdf 824.74KB
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA -designated 100 -year floodplain?*
r Yes r No
8c. What source(s) did you use to make the floodplain determination?*
FEMA - National Flood Hazard Layer Map Viewer

Miscellaneous
I _
Comments
Additional Easement info waiting to be recorded. Site as shown in Construction plans and drawings submitted.
Miscellaneous attachments not previously requested.
Signature
m 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:
Mark Reich, PE
Signature
K13ramlOWIF,Svs-
Date
4/17/2019

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID:
6885-72-6603
6885-82-0034
6885-71-9805
STREET ADDRESS: 0 Highway 66 South Hwy, Kernersville, NC 27284
1470 Fieldmount Rd., Kernersville,NC27284
Please print:
Property Owner:
Property Owner:
Town of Kernersville (Easements and with the power of eminent domain)
Curtis L. Swisher - City Manager
The undersigned, registered property owners of the above noted property, do hereby authorize
Mark Reich, PE
(Contractor / Agent)
of Alley, Williams, Carmen & King, Inc
(Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
P.O. Box 728, Kernersville, NC 27284 (Town of Kernersville)
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature
Authorized Signature
Date: 3 Z 9--1 y Date:

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alley, williamS, Carmen & king, inc. LEGEND NEW IMPACTS FOR:
ENGINEERS, ARCHITECTS & SURVEYORS TOWN OF KERNERSVILLE
740 chapel hill road p.o. box 1179 PERMANENT BUFFER ZONE I IMPACTS BROOKFORD ROAD SANITARY SEWER EXTENSION
FORSYTu U H COUNTY
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USGS Map - Brookford Road Sanitary Sewer Extension
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March 12, 2019
NR Points
❑ Boundary of Destroyed/Removed NR Listing
- SLHD Center Point
DOE Points
SLDOEHD Center Point
Surveyed in NRHD
NR Individual Listing
SL Points
Determined Eligible
DOE Boundaries
SLDOEHD Center Point
Surveyed Only, Gone
NR Listing, Gone
_
SL Individual Entry
SL Boundaries
;
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❑ Determined Eligible Boundary
ElBoth
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NRHD Center Point
SL and DOE entry
Study List Boundary
SL and DOE
DOE and Study List Boundary
Surveyed Points
Blockface- Multiple properties
NR Boundaries
Study List Entry, Gone
Both SL and Determined Eligible Boundary
SL and DOE, Gone
❑ National Register Boundary
Surveyed Only
Blockface in NRHD
A SL and DOE, Gone
DOEHD Center Point
1:9,028
0 0.07 0.15 0.3 mi
0 0.13 0.25 0.5 km
Copyright:© 2013 National Geographic Society, i -cubed
Phil Ross
3/12/19

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Historical Map Brookford Road Sanitary Sewer Extension
March 12, 2019
NR Points
❑
Boundary of Destroyed/Removed NR Listing
* SLHD Center Point
DOE Points
SLDOEHD Center Point
NR Individual Listing
SL Points
A Determined Eligible
DOE Boundaries
SLDOEHD Center Point
NR Listing, Gone
0
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DOE, Gone
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A
SL and DOE entry
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1-1Both DOE and Study List Boundary
NR Boundaries
0
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Surveyed Points
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Surveyed Only
National Register Boundary
SL and DOE, Goner
DOEHD Center Point
Surveyed in NRHD
Surveyed Only, Gone
Surveyed in NRHD, Gone
Blockface- Multiple properties
Blockface in NRHD
1:9,028
0 0.07 0.15
0 0.13 0.25
NC CGIA, USDA FSA, GeoEye, CNES/Airbus DS
0.3 mi
0.5 km
Phil Ross
3/12/19