U-5768_Eng_Form_4345.pdf

U.S. Army Corps of Engineers (USACE)
Form Approved -
APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT
OMB No. 0710-0003
33 CFR 325. The proponent agency is CECW-CO-R.
Expires: 01-08-2018
The public reporting burden for this collection of information, OMB Control Number 0710-0003, is estimated to average 11 hours per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services,
at whs.mc-alex.esd.mbx.dd-dod-information-collections(a)mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall
be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT
RETURN YOUR APPLICATION TO THE ABOVE EMAIL.
PRIVACY ACT STATEMENT
Authorities: Rivers and Harbors Act, Section 10, 33 USC 403; Clean Water Act, Section 404, 33 USC 1344; Marine Protection, Research, and Sanctuaries Act,
Section 103, 33 USC 1413; Regulatory Programs of the Corps of Engineers; Final Rule 33 CFR 320-332. Principal Purpose: Information provided on this form
will be used in evaluating the application for a permit. Routine Uses: This information may be shared with the Department of Justice and other federal, state, and
local government agencies, and the public and may be made available as part of a public notice as required by Federal law. Submission of requested information
is voluntary, however, if information is not provided the permit application cannot be evaluated nor can a permit be issued. One set of original drawings or good
reproducible copies which show the location and character of the proposed activity must be attached to this application (see sample drawings and/or instructions)
and be submitted to the District Engineer having jurisdiction over the location of the proposed activity. An application that is not completed in full will be returned.
System of Record Notice (SORN). The information received is entered into our permit tracking database and a SORN has been completed (SORN #A1145b)
and may be accessed at the following website: http://dpcid.defense.gov/Privacy/SORNslndex/DOD-wide-SORN-Article-View/Article/570115/al 145b-ce.aspxx
(ITEMS 1 THRU 4 TO BE FILLED BY THE CORPS)
1. APPLICATION NO.
2. FIELD OFFICE CODE
3. DATE RECEIVED
4. DATE APPLICATION COMPLETE
(ITEMS BELOW TO BE FILLED BY APPLICANT)
5. APPLICANT'S NAME
8. AUTHORIZED AGENT'S NAME AND TITLE (agent is not required)
First - Wilson Middle - Last - Stroud
First - Ken Middle - Last - Gilland
Company - North Carolina Department of Transportation
Company - HNTB Corporation
E-mail Address - wstroud(aOncdot.gov
E-mail Address - kgilland(abhntb.com
6. APPLICANT'S ADDRESS:
9. AGENT'S ADDRESS:
Address- NCDOT 1582 Mail Service Center
Address- 343 E. Six Forks Road
City - Raleigh State - NC Zip - 2769< Country - USA
City - Raleigh State - NC Zip - 2760< Country -USA
7. APPLICANT'S PHONE NOs. WAREA CODE
10. AGENTS PHONE NOs. WAREA CODE
a. Residence b. Business c. Fax
a. Residence b. Business c. Fax
919-707-6045
919-424-0486
STATEMENT OF AUTHORIZATION
11. 1 hereby authorize, Ken Gilland to act in my behalf as my agent in the processing of this application and to furnish, upon request,
supplemental information in support of this permit application.
DocuSigned by:
7/8/2019
. W-
SI NATYAA ,P,F270E&ICANT DATE
NAME, LOCATION, AND DESCRIPTION OF PROJECT OR ACTIVITY
12. PROJECT NAME OR TITLE (see instructions)
STIP No. U-5768. Widening NC 49 from John Kirk Dr. to 1-485. Realign Back Creek Church Road. Mecklenburg Countv NC
13. NAME OF WATERBODY, IF KNOWN (if applicable)
14. PROJECT STREET ADDRESS (if applicable)
Back Creek
Address from John Kirk Dr. to I-485, Mecklenburg County
15. LOCATION OF PROJECT
35.3089-80.7187
Latitude: �N Longitude: �W
City - Charlotte State- NC Zip -
16. OTHER LOCATION DESCRIPTIONS, IF KNOWN (see instructions)
State Tax Parcel ID Municipality
Section - Township - Range -
ENG FORM 4345, MAY 2018 PREVIOUS EDITIONS ARE OBSOLETE. Page 3 of 1

17. DIRECTIONS TO THE SITE
From Raleigh, take I-40 to 1-85 South. From 1-85 South, take Exit 46 (Mallard Creek Church Road) east to NC 49.
18. Nature of Activity (Description of project, include all features)
The North Carolina Department of Transportation (NCDOT), in coordination with the Charlotte Department of Transportation (CDOT),
proposes to widen NC 49 (University City Boulevard) from John Kirk Drive to I-485. The project will also realign SR 2827 (Back Creek
Church Road (BCCR)) to intersect with NC 49 at SR 2833 (Mallard Creek Church Road). The current at -grade intersection of BCCR and
North Carolina Railroad (NCRR)/Norfolk Southern Railroad (NS) just south of NC 49 will be closed in conjunction with these
improvements.
The project would widen NC 49 to 6 lanes, mostly within existing right of way. The project would extend Old Concord Road to the
realigned BCCR and install a roundabout at the intersection of John Kirk Drive and Old Concord Road. The project would extend Thomas
Combs Drive to Mallard Creek Church Road. The nroiect would realign and widen BCCR on new location to the intersection of Mallard
19. Project Purpose (Describe the reason or purpose of the project, see instructions)
The primary purposes of the proposed project are to reduce traffic congestion, improve traffic flow, and enhance traffic operations on NC 49.
Other purposes are to improve safety and enhance train and vehicle operations. The screening criteria for this area:
• Achieve an overall Level of Service (LOS) D for intersections along the project corridor in the design year (2040).
• Maintain network connectivity from within the existing road network.
• Safely accommodate multi -modal uses of the corridor.
USE BLOCKS 20-23 IF DREDGED AND/OR FILL MATERIAL IS TO BE DISCHARGED
20. Reason(s) for Discharge
The project would require crossing 10 (Alternative 1) or 9 (Alternative 2) streams and 4 (Alternative 1) or 7 (Alternative 2) wetlands. Based
on a preliminary hydraulic study, Alternative 1 has three major crossings (requiring structures that are 72 inches or greater in diameter). One
existing major crossing would not change, and a culvert is proposed for the crossing of a UT to Back Creek. Abridge is proposed at the
crossing of Back Creek to minimize impacts. All other crossings can be contained in smaller pipes. For Alternative 2, there would be two
major crossings. One existing major crossing would not change. A bridge is proposed at the crossing of Back Creek to minimize impacts
and avoid impacts to a mitigation site. All other crossings can be contained in smaller pipes. Impacts to streams and wetlands will be
avoided and minimized to the greatest practicable extent. Some jurisdictional impacts are unavoidable. Anticipated stream and wetland
21. Type(s) of Material Being Discharged and the Amount of Each Type in Cubic Yards:
Type Type Type
Amount in Cubic Yards Amount in Cubic Yards Amount in Cubic Yards
TBD TBD TBD
22. Surface Area in Acres of Wetlands or Other Waters Filled (see instructions)
Acres BCCR Alternative 1 and NC 49 - 0.76 acre, BCCR Alternative 2 and NC 49 - 2.3 acres
or
Linear Feet BCCR Alternative 1 and NC 49 - 2,730 linear feet, BCCR Alternative 2 and NC 49 2,427 linear feet of stream impacts
23. Description of Avoidance, Minimization, and Compensation (see instructions)
Jurisdictional determinations will be made once a LEDPA has been agreed upon. Through development of the functional designs of the
Design Study Alternatives (DSAs), NCDOT has attempted to avoid or minimize impacts to streams and wetlands to the greatest practicable
extent. This included developing alignments and intersection configurations for the DSAs that avoided these resources as much as possible,
while also minimizing impacts to other resources. NCDOT will continue to seek ways to avoid and minimize impacts in further design
efforts for the selected alternative.
ENG FORM 4345, MAY 2018 Page 3 of 2

24. Is Any Portion of the Work Already Complete? ❑ Yes ❑X No IF YES, DESCRIBE THE COMPLETED WORK
25. Addresses of Adjoining Property Owners, Lessees, Etc., Whose Property Adjoins the Waterbody (if more than can be entered here, please attach a supplemental list).
a. Address -
City - State - Zip -
b. Address -
City - State - Zip -
c. Address -
City - State - Zip -
d. Address -
City - State - Zip -
e. Address -
City - State - Zip -
26. List of Other Certificates or Approvals/Denials received from other Federal, State, or Local Agencies for Work Described in This Application.
AGENCY TYPE APPROVAL' IDENTIFICATION DATE APPLIED DATE APPROVED DATE DENIED
NUMBER
* Would include but is not restricted to zoning, building, and flood plain permits
27. Application is hereby made for permit or permits to authorize the work described in this application. I certify that this information in this application is
complete and accurate. I further certify that I possess the authority to undertake the work described herein or am acting as the duly authorized agent of the
applicant.
DocuSigned by:
w. 7/8/2019
SIGNA URE OF APPLICANT DATE SIGNATURE OF AGENT DATE
F7BCODE327DC438...
The Application must be signed by the person who desires to undertake the proposed activity (applicant) or it may be signed by a duly
authorized agent if the statement in block 11 has been filled out and signed.
18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of the United States
knowingly and willfully falsifies, conceals, or covers up any trick, scheme, or disguises a material fact or makes any false, fictitious or fraudulent
statements or representations or makes or uses any false writing or document knowing same to contain any false, fictitious or fraudulent
statements or entry, shall be fined not more than $10,000 or imprisoned not more than five years or both.
ENG FORM 4345, MAY 2018 Page 3 of 3