20230733 Ver 1_revised impact table_20230807

D. Proposed Impacts Inventory
1. Impacts Summary
la. Where are the impacts associated with your project
(check all that apply):
0 Wetlands
0 Buffers
❑ Pond Construction
0 Streams - tributaries
❑ Open Waters
2. Wetland Impacts
If there are wetland impacts proposed on the site, complete this table for each wetland area impacted.
2a.
2a1.
2b.
2c.
2d.
2e.
2f.
2g.
Site #*
Impact
Impact
Wetland Name*
Wetland Type*
Forested
Jurisdiction
Impact Area
Reason/Type*
Duration*
?*
Type*
(ac)*
W1
Fill (Incl.
Permanent
WA
Bottomland
Yes
Both
0.069
Riprap)
Hardwood
Forest
W2
Fill (Incl.
Permanent
WB
Bottomland
Yes
Both
0.002
Riprap)
Hardwood
Forest
W3
Fill (Incl.
Permanent
WC
Bottomland
Yes
Both
0.007
Riprap)
Hardwood
Forest
W4
Fill (Incl.
Permanent
WD
Bottomland
Yes
Both
0.010
Riprap)
Hardwood
Forest
W5
Fill (Incl.
Permanent
WE
Bottomland
Yes
Both
0.004
Riprap)
Hardwood
Forest
W6
Choose one
Temp/
Click to enter
Choose one
Y/N
Choose one
Click to
Perm
enter
2g1. Total temporary wetland impacts
Click to enter. ac
2g2. Total permanent wetland impacts
0.092 ac
2g3. Total wetland impacts
0.092 ac
2h. Comments:
Permanent wetland impacts W1, W2, W3 and W4 are associated with proposed roads that will provide access to the
site. The impacts include the associated grading limits to bring the roads up to grade, head walls and end walls and
associated rip rap to be placed as fill. Permanent Impact W5 is associated with fill from a slope associated with the
building pad for apartment building #2.
Page 9 of 22 PCN Form - Version 1.5, September 2020

3.
Stream Impacts
If there are perennial or intermittent stream/ tributary impacts (including temporary impacts) proposed on the site,
complete this table for all stream/ tributary sites impacted.
** All Perennial or Intermittent streams must be verified by DWR or delegated local government
Site #*
3a.
Impact Reason/
Type*
3b.
Impact
Duration*
3d.
Stream Name*
3e.
Stream
Type*
3f.
Jurisdiction
Type*
3g.
Stream Width
(avg ft) *
3h.
Impact length
(linear ft)
S1
Crossing/ Culvert
Permanent
SA
Perennial
Both
5
62
S2
Fill (Intl. Riprap)
Permanent
SA
Perennial
Both
5
30
S3
Dewatering
Temporary
SA
Perennial
Both
5
5
S4
Crossing/ Culvert
Permanent
SA
Perennial
Both
5.7
93
S5
Fill (Incl. Riprap)
Permanent
SA
Perennial
Both
5.7
30
S6
Dewatering
Temporary
SA
Perennial
Both
5.7
10
S7
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S8
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S9
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S10
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S11
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S12
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S13
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S14
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
S15
Choose one
Temp/ Perm
Click to enter
Per/Int
Choose one
Click to enter
Click to enter
3i1.
Total jurisdictional ditch impact:
Click to enter. linear ft
3i2.
Total permanent stream impacts:
215 linear ft
M.
Total temporary stream impacts:
15 linear ft
34.
Total stream and ditch impacts:
230 linear ft
3j.
Comments:
Crossing 1 - The culvert/head walls and end walls will impact 0.0071 acres of stream channel. The rip rap will
impact 0.0034 acres of stream channel. The pump around will temporarily impact 0.0006 acres of stream
channel.
Crossing 2 - The culvert/head walls and end walls will impact 0.0122 acres of stream channel. The rip rap will
impact 0.0039 acres of stream channel. The pump around will temporarily impact 0.0013 acres of stream
channel.
Page 10 of 22 PCN Form - Version 1.5, September 2020

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., individually list all open water impacts in the table below.
4a.
4b.
4c.
4d.
4e.
4e1.
4f.
Site #*
Impact Reason/
Impact
Waterbody Name*
Waterbody
Jurisdiction
Impact area (ac)*
Type*
Duration*
Type*
Type*
01
Choose one
Temp/
Click to enter.
Choose one
Choose one
Click to enter.
Perm
02
Choose one
Temp/
Click to enter.
Choose one
Choose one
Click to enter.
Perm
03
Choose one
Temp/
Click to enter.
Choose one
Choose one
Click to enter.
Perm
04
Choose one
Temp/
Click to enter.
Choose one
Choose one
Click to enter.
Perm
4g.
Total temporary open water impacts
Click to enter. ac
4g.
Total permanent open water impacts
Click to enter. ac
4g.
Total open water impacts
Click to enter. ac
4h.
Comments:
Open water impacts are not proposed.
5.
Pond or Lake Construction
If pond or lake construction is proposed, complete
the table
below. (*This
does NOT include offline stormwater
management ponds.)
5a.
5b.
5c.
5d.
5e.
Pond ID
Proposed use or
Wetland Impacts (ac)
Stream
Impacts (ft)
Upland
#
purpose of pond
Impacts (ac)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
Click to
Click to
Click to
Click to
Click to
Click to
Click to
enter.
enter.
enter.
enter.
enter.
enter.
enter.
P2
Choose one
Click to
Click to
Click to
Click to
Click to
Click to
Click to
enter.
enter.
enter.
enter.
enter.
enter.
enter.
5f.
Total
Click to
Click to
Click to
Click to
Click to
Click to
Click to
enter.
enter.
enter.
enter.
enter.
enter.
enter.
5g.
Comments:
Pond or lake construction is not proposed.
5h.
Is a dam high hazard permit required?
❑ Yes ❑ No
If yes, permit ID no.:
Click to enter.
5i.
Expected pond surface area (acres):
Click to enter.
5j.
Size of pond watershed (acres):
Click to enter.
5k.
Method of construction:
Click to enter.
Page 11 of 22 PCN Form - Version 1.5, September 2020

6. Buffer Impacts (DWR requirement)
If project will impact a protected riparian buffer, then complete the chart below. Individually list all buffer impacts.
6a. Project is in which protected basin(s)?
* (Check all that apply.)
❑ Neuse ❑ Tar -Pamlico ❑ Catawba
❑ Jordan ❑ Goose Creek ❑x Randleman
❑ Other: Click to enter.
Site #*
6b.
Impact Type*
6c.
Impact Duration*
6d.
Stream Name*
6e.
Buffer
Mitigation
Required?*
6f.
Zone 1 Impact*
(sq ft)
6g.
Zone 2 Impact*
(sq ft)
B1
Crossing/ Culvert/
Bridge
Permanent
SA/Unnamed
No
7,654
4,052
B2
Crossing/ Culvert/
Bridge
Permanent
SA/Unnamed
No
7,603
4,390
B3
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B4
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B5
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B6
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B7
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B8
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B9
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
B10
Choose one
Temp/ Perm
Click to enter.
Y/N
Click to enter.
Click to enter.
6h. Total temporary impacts:
Zone 1: Click to enter. sq ft
Zone 2: Click to enter. sq ft
6h. Total permanent impacts:
Zone 1: 15,257 sq ft
Zone 2: 8,442 sq ft
6h. Total combined buffer impacts:
Zone 1: Click to enter. sq ft
Zone 2: Click to enter. sq ft
6i. Comments:
Buffer impacts at each of the crossings is less than 1/3 of an acre and 150 linear feet. Buffer mitigation is not proposed.
Buffer authorization for the proposed impacts is being obtained from the City of High Point.
Please attach supporting documentation (impact maps, plan sheets, etc.) for the proposed project.
Page 12 of 22 PCN Form - Version 1.5, September 2020