20201004 Ver 1_3-2020-11-10-REVISED-PCN-NCDWR-COMMENT_20201110 (2)

C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below
for your project (check
❑ Buffers
all that apply):
Waters ❑ Pond Construction
X Wetlands X Streams — tributaries
X
Open
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a.
Wetland impact
number
Permanent (P) or
Temporary (r)
2b.
Type of impact
2c.
Type of wetland
2d.
Forested
2e.
Type of jurisdiction
Corps (404,10) or
DWQ (401, other)
2f.
Area of
impact
(acres)
W1 W5 W6 W7
Flooding
Unknown
No
BOTH
0.328
W2 W9 W1C W11
Fill
Mountain Bog
No
BOTH
0.019
W3
W4 W8
Fill
Unknown
Yes/No
BOTH
0.05
W5
Choose one
Choose one
Yes/No
-
W6 -
Choose one
Choose one
Yes/No
-
2g. Total Wetland Impacts:
0.397
2h. Comments:
W5. W6. W7 - Temp. 0.328 Ac: W8, W9. W10. W11 - Permanent, 0.069 Ac
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site. then complete this
question for al stream sites impacted.
3a.
Stream impact
number
Permanent (P) or
Temporary (T)
3b.
Type of impact
3c.
Stream name
3d.
Perennial (PER) or
intermittent (INT)?
3e.
Type of
jurisdiction
3f.
Average
stream
width
(feet)
3g.
Impact
length
(linear
feet)
S1 S5
Flooding
S5
PER
BOTH
3
61
S2 S6
Dam construction
S6
PER
BOTH
2
40
S3 S6
Flooding
S6
PER
BOTH
2
48
S4 Thompson Ri'
Rock Vane Crossing
Thompson River
PER
BOTH
18
183
S5 Thompson Ri'
Stabilization
Thompson River
PER
BOTH
18
150
S6 S3,S6
Daylighting - Culvert Remo\
S3.S6
PER
BOTH
3
40
3h. Total stream and tributary impacts
522
3i. Comments:
Permanent Impacts - S6 dam construction. S6 Flooding. S5 Flooding - 149 L.F.
Temporary Impacts - Thompson River rock vane and bank stabilization, S3 daylighting. S6 daylighting - 243 L.F.
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PCN Form — Version 1.4 January 2009

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 individually 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 P
Lake Pickens
Fill
Lake
0.0005
O2 -
Choose one
Choose
03 -
Choose one
Choose
04 -
Choose one
Choose
4f. Total open water impacts
4g. Comments: Fill for DOCK Pilings
5. Pond or Lake Construction
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 any 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 (T)
6c.
Reason for impact
6d.
Stream name
6e.
Buffer
mitigation
required?
6f.
Zone 1
impact
(square
feet)
6g.
Zone 2
impact
(square
feet)
B1 -
Yes/No
B2 -
Yes/No
B3 -
Yes/No
B4 -
Yes/No
B5 -
Yes/No
B6 -
Yes/No
6h. Total Buffer Impacts:
6i. Comments:
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