20160571 Ver 1_PCN REVISED SHEET 5_20160622

4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individuall list all open water impacts below.
4a. 4b. 4c. 4d. 4e.
Open water Name of waterbody
impact number (if applicable) Type of impact Waterbody Area of impact (acres)
Permanent (P) or type
Temporar T
01 - Choose one Choose
Q2 - Choose one Choose
03 - Choose one Choose
04 - Choose one Choose
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If pond or lake construction ro osed, then com lete the chart below.
5a. 5b. 5c. 5d. 5e.
Pond ID number Proposed use or Wetland Impacts (acres) Stream Impacts (feet) Upland
purpose of pond (acres)
Flooded Filled Excavated Flooded Filled Excavated
P1 Choose one
P2 Choose one
5f. Total:
5g. Comments:
5h. Is a dam high hazard permit required? ❑ Yes ❑ No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If an impacts require miti ation, then ou MUST fill out Section D of this form.
6a. Project is in which protected basin? ❑ Neuse � Tar-Pamlico �tawba QX ndleman Oth�
6b. 6c. 6d. 6e. 6f. 6g.
Buffer Impact Reason for impact Stream name Buffer Zone 1 Zone 2
number — mitigation impact impact
Permanent (P) or required? (square (square
Tem orar T feet feet
g� P Greenway bridge E. Fork Deep River No 917 604
g2 P Greenway bridge Two Unnamed Tributaries in Wetland No 0 0
63 P Boardwalk and bridge Unnamed Tributary No 3,397 5,216
B4 P Greenway bridge Unnamed Tributary No 878 451
g5 P Greenway bridge Unnamed Tributary No 1,404 760
B6 P No
6h. Total Buffer Impacts: 6,596 7,031
6i. COmm2ntS: Trees and vegetation will be cut flush with the ground to construct elevated boardwalk and bridges in buffers. No grubbing will take
place within the stream buffers.
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