Creek Project

State of North Carolina
Water Resources
Environmental Quality
Department of Environmental Quality
Division of Water Resources
15A NCAC 02H .0506(b)(4) Water Quality Certification,
Notification of Work in Trout Watersheds
FORM: TroutWS 11-2017
Notification of Work in Trout Watersheds Form.
A.
Applicant Information
1.
Processing
la.
Specify Nationwide Permit (NWP) number: ,� or General Permit (GP) number:
1 b.
Has the NWP or GP number been verified by the Corps?
❑ Yes ❑ No
1 c.
Does the project meet all the Conditions of the applicable Water Quality
Certification
❑ Yes ❑ No
Please note that your project may be subject to the Sediment and Erosion Control Program and/or Trout Buffers
implemented by the Division of Energy, Mineral, and Land Resources. Find more info at:
https:/Ideq.nc.gov/abouVd ivis ions/energy-mineral-land-resources/erosion-sed iment-control
2.
Project Information
2a.
Name of project:
2b.
County:
2c.
Nearest municipality / town:
C'S vr1
3.
Owner Information
3a.
Name(s) on Recorded Deed:
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3b.
Responsible Party (for LLC if
applicable):
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3c.
Street address:
31ah --4)'n,, } c'l
3d.
City, state, zip:
to yr�'ll c 1,2 610
3e.
Telephone no.:
3f.
Email address:
L�U,C�ir'✓1 375' ei/Sc)vT-h
4.
Agent/Consultant Information (if applicable)
4a.
Name:
4b.
Business name
(if applicable):
4c.
Telephone no.:
4d.
Email address:
B.
Project Information
1.
Property Identification
1a.
Property identification no. (tax PIN or parcel ID):
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Latitude: Longitude: -
(DD.DDDDDD) (-DD.DDDDDD)
1 b.
Site coordinates (in decimal degrees):
2.
Project Description

2a. Explain the purpose of the proposed project (continue on back):
2b. Describe the overall project detail, including the type of equipment to be used:
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C. Stream Impacts: Please list all proposed impacts to the stream
la. Stream Name: /e- r,,4
1b.
Type of impact
Average stream
width (linear feet)
Impact length
(linear feet)
[Bank Stabilization - Sloping and Revegetating0
It {
t
❑ Bank Stabilization - Sloping and Riprap/Armoring
❑ Bank Stabilization - Gabion Baskets / Retaining Wall
❑ Culvert Installation
Culvert Diameter:
❑ Temporary Impacts for required dewatering activities
❑ Other (describe): _
1 c. Comments:
Owner/Agent's Printed Name
Date
Owner/Agent's Signature
(Agent's signature is valid only if an authorization letter from the owner is
provided.)