20221490 Ver 1_P22044-DOHM Updated PCN Impact Table_20221222

3a. Reason for
impact*(.)
3b.Impact
type*
3c. Type of
impact*
3d. S. name*
3e. Stream
Type*(?)
3f. Type of
Jurisdiction*
3g. S.
width*
3h.
Impact
length*
si
UT-1
Perenn
69
k
Stream Cro
Perma ''
Culvert
Both
4
Average
(feet)
(linear
feet)
Stream Cro
LWheat CreJ
Perma
Other
Perenn
Both '' 1
130
40
Average
(feet)
(linear
feet)
S3
4
Culvert Rer
Tempc ''
Stabilizatio
UT-1
Perenn
Both
40
x
Average
(feet)
(linear
feet)
S4'
Culvert Rer
Tempc
Stabilizatio
UT-2
Perenn ''
Both 1 1
2
20
X
(linear
feet)
Average
(feet)
C.
Ford Remo
LWheat CreJ
Tempc
Stabilizatio
Perenn ''
Both v
30
20
X
Average
(feet)
(linear
feet)
S6
Bank Stabil
Tempc ''
Bank Stabi '
Wheat CreE
Perenn ''
Both
[30
40
(linear
feet)
Average
(feet)
Add another impact
** All Perennial or Intermittent streams must be verified by DWR or delegated local government.
3i. Total jurisdictional ditch impact in square feet:
0
3i. Total permanent stream impacts:
109
3i. Total temporary stream impacts:
120
3i. Total stream and ditch impacts:
229

3j. Comments:
One 20 feet culvert removal along UT-1 will be in the same
location where the 69 feet culvert is to be installed.

1. Diffuse Flow Plan
la. Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian
Buffer Protection Rules?
0 Yes 0 No
For a list of options to meet the diffuse flow requirements, click here
(https://files.nc.gov/ncdeq/Water%20Quality/Surface/020Water%20Protection/401 /Buffer%20Clarification%20Memos/Options
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250? *
Yes No
Comments:
G. Supplementary Information
1. Environmental Documentation
la. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state)
land?*
Yes No
2. Violations (DWR Requirement)

2a. Is the site in violation of DWR Water Quality Certification Rules (15A NCAC 2H .0500), Isolated Wetland Rules
(15A NCAC 2H .1300), or DWR Surface Water or Wetland Standards or Riparian Buffer Rules (15A NCAC 2B
.0200)? *
Yes No
3. Cumulative Impacts (DWR Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in additional development,
which could impact nearby downstream water quality? *
Yes No
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project? *
Yes No 0 N/A
5. Endangered Species and Designated Critical Habitat (Corps
Requirement)
5a. Will this project occur in or near an area with federally protected species or habitat? *
Yes No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
Yes No
5d. Is another Federal agency involved? *
Yes No
5e. Is this a DOT project located within Division's 1-8?*
Yes No
5f. Will you cut any trees in order to conduct the work in waters of the U.S.?*
Yes No
5g. Does this project involve bridge maintenance or removal?
0 Yes 0 No
Unknown
Link to the NLEB SLOPES document: http://saw-reg.usace.army.mil/NLEB/1-30-17-signed_NLEB-SLOPES&apps.pdf (http://saw-
reg.usace.army.mil/NLEB/1-30-17-signed_NLEB-SLOPES&apps.pdf)

5h. Does this project involve the construction/installation of a wind turbine(s)?* *
Yes 0 No
5i. Does this project involve (1) blasting, and/or (2) other percussive activities that will be conducted by
machines, such as jackhammers, mechanized pile drivers, etc.? *
Yes No
5j. What data sources did you use to determine whether your site would impact Endangered Species or
Designated Critical Habitat?*
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat? *
Yes No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat? *
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
Link to the State Historic Preservation Office Historic Properties Map (does not include archaeological data:
http_//gis.ncdcr.gov/hpoweb/ (http://gis.ncdcr.gov/hpoweb/)
7a. Will this project occur in or near an area that the state, federal or tribal governments have designated as
having historic or cultural preservation status (e.g., National Historic Trust designation or properties significant
in North Carolina history and archaeology)? *
Yes No
7b. What data sources did you use to determine whether your site would impact historic or archeological
resources? *

8. Flood Zone Designation (Corps Requirement)
Link to the FEMA Floodplain Maps: https://msc.fema.gov/portal/search (https://msc.fema.gov/portal/search)
8a. Will this project occur in a FEMA-designated 100-year floodplain?
Yes No
8c. What source(s) did you use to make the floodplain determination? *
Miscellaneous
Comments
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By checking the box and signing below, I certify that:

• The project proponent hereby certifies that all information contained herein is true, accurate, and complete to
the best of my knowledge and belief'; and
• The project proponent hereby requests that the certifying authority review and take action on this CWA 401
certification request within the applicable reasonable period of time.
• I have given true, accurate, and complete information on this form;
• I agree that submission of this PCN form is a "transaction" subject to Chapter 66, Article 40 of the NC General
Statutes (the "Uniform Electronic Transactions Act");
• I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General
Statutes (the "Uniform Electronic Transactions Act");
• I understand that an electronic signature has the same legal effect and can be enforced in the same way as a
written signature; AND
• I intend to electronically sign and submit the PCN form.
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