20160441 Ver 1_Impact Inventory_20160615

C. Proposed Impacts Inventory
1. Impacts Summary
1a. Which sections were completed below for your project (check all that apply):
❑X Wetlands ❑ Streams — tributaries ❑X Buffers ❑ Open Waters ❑ Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a. 2b. 2c. 2d. 2e. 2f.
Wetland impact Type of impact Type of wetland Forested Type of jurisdiction Area of
number Corps (404,10) or impact
Permanent (P) or DWQ (401, other) (acres)
Tempora T
W1 P Fill Coastal No CAMA 0.004
�/2 - Choose one Choose one Yes/No -
�/3 - Choose one Choose one Yes/No -
�/4 - Choose one Choose one Yes/No -
�/5 - Choose one Choose one Yes/No -
�/6 - Choose one Choose one Yes/No -
2g. Total Wetland Impacts: 0.004
2h. Comments:
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a. 3b. 3c. 3d. 3e. 3f. 3g.
Stream impact Type of impact Stream name Perennial (PER) or Type of Average Impact
number intermittent (INT)? jurisdiction stream length
Permanent (P) or width (linear
Temporary (T) (feet) feet)
S1 - Choose one - -
$2 - Choose one - -
S3 - Choose one - -
S4 - Choose one - -
S5 - Choose one - -
S6 - Choose one - -
3h. Total stream and tributary impacts
3i. Comments:
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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 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? ❑ Neuse 0 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 ShoulderStabilization Pamlico River No 100 10
B2 P Shoulder Stabilization Pamlico River No 600 0
B3 - Yes/No
B4 - Yes/No
B5 - Yes/No
B6 - Yes/No
6h. Total BufFer Impacts: 700 10
6i. Comments:
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