20100623 Ver 1_More Info Received_20100805

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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 individual) list all open water impacts below.
4a.
Open water
impact number
Permanent (P) or
Temporary (T) 4b.
Name of waterbody
(if applicable) 4c.

Type of impact 4d.

Waterbody
type 4e.

Area of impact (acres)
01 moose one choose Z J,? ??i2 Lt9s
02 - Choose one Choose
03 - Choose one Choose
04 - Choose one Choose
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Constriction
If pond or lake construction proposed, then complete the chart below.
5a.
Pond ID number 5b.
Proposed use or
purpose of pond 5c.
Wetland Impacts (acres) 5d.
Stream Impacts (feet) 5e.
Upland
(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 mitigation, then you MUST fill out Section D of this form.
6a. Project is in which protected basin? ? Neuse ? Tar-Pamlico ? Catawba ? Randleman ? Other:
6b.
Buffer Impact
number -
Permanent (P) or
Temporary 6c.
Reason for impact 6d.
Stream name

D 6e.
Buffer
mitigation
required? 6f.
Zone 1
impact
(square
feet 6g.
Zone 2
impact
(square
feet
B1 - Yes/No
B2 - l
U11
G
f) Yes/No
B3 - ,,
_ 4
Liu Yes/No
B4 - ViETiq'dUSANp QUALITY YesNo
65 - Yes/No
B6 - Yes/No
6h. Total Buffer Impacts:
61. Comments:
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