20150030 Ver 1_Greene 258 PCN revised pages 5 and 6 (2)_20150305

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
Tempora T
01 - Choose one Choose
O2 - 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 proposed, then complete 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? ❑X Neuse � Tar-Pamlico � Catawba � Randleman ❑ Other:
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
Tempora T feet feet
B� P Fill Sowell Run No 4,815 320
B2 - Yes/No
B3 - Yes/No
B4 - Yes/No
B5 - Yes/No
B6 - Yes/No
6h. Total BufFer Impacts: 4,815 320
61. Comments: Zone 1 Impacts - 0.1105 Acres, Zone 2 Impacts - 0.0073 Acres
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D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
There are 4,155 sq.ft. of buffer zone 1 impacts and 320 sq.ft. of zone 2 impacts due to the installation of a 60" rcp.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Use of existing roadway to operate construction equipment.
2. Com ensato Miti ation for Im acts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for � Yes ❑X No
impacts to Waters of the U.S. or Waters of the State?
2b. If yes, mitigation is required by (check all that apply): ❑ DWQ ❑ Corps
❑ Mitigation bank
2c. If yes, which mitigation option will be used for this
project? ❑ Payment to in-lieu fee program
❑ Permittee Responsible Mitigation
3. Com lete if Usin a Miti ation Bank
3a. Name of Mitigation Bank:
Type: Choose one Quantity:
3b. Credits Purchased (attach receipt and letter) Type: Choose one Quantity:
Type: Choose one Quantity:
3c. Comments:
4. Com lete if Makin a Pa ment to In-lieu Fee Pro ram
4a. Approval letter from in-lieu fee program is attached. ❑ Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature: Choose one
4d. Buffer mitigation requested (DWQ only): square feet
4e. Riparian wetland mitigation requested: acres
4f. Non-riparian wetland mitigation requested: acres
4g. Coastal (tidal) wetland mitigation requested: acres
4h. Comments:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
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PCN Form — Version 1.4 January 2009