IMPAIRED AND IMPACTED STREAM/WATERSHED SURVEY

Please review and answer as many of the questions below as possible to the best of your ability. If you are not sure of how to answer a question, leave it blank and follow up with DSWC or DWR staff. Please submit this document using our online form by the Project Year due date. If you have questions regarding the survey feel free to contact Ken Parks at r 919-715-6100.

NOTE: This hard copy is meant for reference only. Please only submit the online version of this form and save this version for your records.

Your District: ______

Contact for Survey:______

Phone: ______E-mail:______

**Completing this survey is voluntary. Submitted information will help guide resource agency staff to conduct further investigations, assessments, identify funding sources, and/or implement remedial actions.**

Stream Name: ______

River Basin: ______Subbasin: ______

Assessment Unit Number: ______

HUC (12-Digit Watershed Code): ______

County: ______Municipality: ______

Is this stream listed as Impaired or Impacted? (Refer to the Assessment and Use Support Table in the DWQ Basinwide Plan or Integrated Report. Ratings of a “Good-Fair” are considered to be impacted or those streams that you assess to be impacted)

Refer to the ParametersReasons for Rating column in the Assessment and Use Support Table found in the Basinwide Plan or Integrated Report: 2012 303(d) List

Noted Stressors: ______

Noted Sources: ______

Date of most recent Basinwide Plan: ______

Brief description of what the plan says about this stream: ______

______

Is there a current active monitoring program on this stream segment? Yes No.

If yes, what are the samples showing? ______

______

Does the watershed encompass a Public Water Supply? Yes No.

If yes, please list the name of the public water supply: ______

Is the identified stream a natural stream or a stream modified by human activity? (e.g. channelized)

Natural Modified

If ‘modified’, describe modification: ______

Is there an apparent sediment problem in the streambed of the impaired or impacted stream segment?

Yes No (If ‘No’, skip the next question.)

If yes, is the excessive sedimentation coming from:

Streambanks
Adjacent land area
Other sources within the watershed upstream of the identified stream segment
A tributary feeding into the identified stream segment
In-stream projects that are causing stream disturbance
If you indicated ‘a tributary’ in the previous question, name the tributary below:

______

If you indicated ‘in-stream projects’ in the previous question, what type of project is it and are the stream disturbing effects from the projects temporary or long term?
______

Additional information (add any information here that helps describe the current water quality problems within the identified stream segment).
______

Select applicable sources of pollution delivery into the identified stream segment from the upland watershed area: (check all that apply)

Cropland
Pasture/Hayland
Forestland
Road construction
Construction other than road
Mining
Tributary stream (include name)______
Other (list source) ______

Check the items listed below if they appear in this stream:

Channelization
Livestock access
Pesticide mixing stations
Outfall pipes and sources (stormwater, septic systems, unknown, etc.)
Permitted discharges
Development
Road crossings
Fish hatchery or farms
Periods of no flow
Swamp drainage

Failing septic systems

Failing storm drains

Logging

Mining
Other (list items)______

Estimate the percentage of stream miles in the watershed that are buffered: ______%

Estimate of average buffer width (feet): ______feet

What is the typical buffer vegetation (grass, shrubs, trees, etc.): ______

Describe land use changes in the watershed over the past 5-10 years: ______

If possible, describe the extent of existing BMPs in the watershed area (within the past 10 years):

Name of BMP (e.g. livestock exclusion, stormwater retention, streamside buffers, etc) / Est. Units/ Amount
(e.g. 28 units) / Funding Source(e.g. ACSP, EQIP, 319, EEP) / Cost ($)

Recommended Actions to Address Identified Problems: (e.g. riparian buffer rehabilitation; livestock exclusion; agrichemical handling facility; landowner education/outreach; stormwater retention pond, etc) ______

Potential barriers or limiting factors to solving identified problems: ______

Resources (other than cost share) needed to solve identified problems (show resources for staff, equipment):

Item / Units/ AmountNeeded / Estimated Cost ($)

Estimate the extent of BMPs needed on this stream segment (please list in order of priority):

Name of BMP(e.g. livestock exclusion) / QuantityNeeded (acres, feet, units, etc.) / Estimated Cost ($)


Special Watershed Issues

Pipe and Drainage Ditch Inventory

This information applies to a: Pipe Drainage Ditch Other: ______

Describe the discharge flow from the pipe or ditch (if any):
Rate of flow: None Steady Intermittent Heavy Trickle
Appearance: Clear Foamy Turbid Oily sheen Colored
______

Comments on pipe or drainage ditch observations (Use this space to identify specific facilities, or provide additional information on the drainage or stream condition noted above.)

______

Is this watershed covered by an active local watershed management plan?

Yes No

If so, what remediation efforts does the watershed plan recommend?

______

To your knowledge, is this watershed management plan an approved 9-element plan?

9-element plans must be reviewed and approved by the Division of Water Resources or EPA Staff.

Yes No

Is this watershed prioritized on your district ranking form?

Yes No

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Thank you for completing this survey!These recommendations can be used to develop remediation proposals for the Ag Cost-Share Program, Section 319, Clean Water Management Trust Fund, and other grant sources. Survey results will also help the DWQ’s Basinwide Planning Program in developing basinwide plans and to assist you in developing watershed plans for your watershed of interest.

NOTE: This hard copy is meant for reference only. Please only submit the online version of this form and save this version for your records.

Please contact Ken Parks at 919-715-6100 for assistance as needed or email Ken .

Please collect digital photos, aerial photos, GIS maps and any additional information that you would like to provide about this stream and its watershed. Please send any relevant documentation to Joey Hester.

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