20210189 Ver 1_Revised (PCN) Pages_20210524

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? This includes other
separate and distant crossing for linear projects that require Department of the Army
authorization but don’t require pre-construction notification.
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for
each wetland area impacted.
"W." will be used in the table below to represent the word "wetland".
2a. Site
#(?)*
2a1
Reason (?)*
2b. Impact
type (?)*
2c. Type of W.*2d. W.
name *
2e.
Forested *
2f. Type of
Jurisdicition *
(?)
2g.
Impact
area *
Add
2g. Total Temporary Wetland Impact
D. Proposed Impacts Inventory
Wetlands Streams-tributaries Buffers
Open Waters Pond Construction
W1 Fill P Non-Tidal Fr Wetland Yes Both 
(acres)
W2 Fill P Non-Tidal Fr Shorelin No Both 
(acres)
0.000
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2g. Total Permanent Wetland Impact
2g. Total Wetland Impact
2i. Comments:
6. Buffer Impacts (for DWR)
If project will impact a protected riparian buffer, then complete the chart below.
Individually list all buffer impacts below.
6a. Project is in which protect basin(s)?*
6b. Impact Type (?)*6c. Per or
Temp (?)*
6d. Stream
name *
6e. Buffer
mitigation
required?*
6f. Zone 1
impact *
6g. Zone
2 impact *
0.092
0.092
Impact W1 associated with fill material for proposed
swim beach. Impact W2 associated with fill material
for trail improvements.
Check all that apply.
Neuse Tar-Pamlico
Catawba Randleman
Goose Creek Jordan Lake
Other
Fill - Swim Beac P Open Wate Yes 1,731
(square
feet)
3,290
(square
feet)
Trails P Open Wate No 19,490
(square
feet)
8,290
(square
feet)
Fishing Piers P Open Wate No 1,980
(square
feet)
1,320
(square
feet)
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Add another impact
6h. Total buffer impacts:
Zone 1 Zone 2
Total Temporary
impacts:
Zone 1 Zone 2
Total Permanent
impacts:
Zone 1 Zone 2
Total combined buffer
impacts:
6i. Comments:
Pedestrian Bridg P Stream 1 No 250
(square
feet)
(square
feet)
Pedestrian Bridg P Stream 2 No 250
(square
feet)
(square
feet)
Pedestrian Bridg P Stream 3 No 500
(square
feet)
(square
feet)
0.00 0.00
24,201.00 12,900.00
24,201.00 12,900.00
Impacts associated with fill for proposed swim
beach and trails, and pier and bridge structures.
Page 11 of 18New Submission
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