20080760 Ver 3_Determination Request (4)_20230530

Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all
mandatory questions are answered.
Project Name:*
Is this a transportation project?*
Is this request for a mitigation site?
What type of request is this?*
Owner Information
Country Club Creek Subdivision
Yes No
Yes No
Buffer
Isolated Wetland
Check all that apply.
IP Stream Determination
Stream
Name on the Recorded Deed: * Garris Evans Lumber Company
Responsible Party : John H. Evans - East Domus Development, LLC
(for LLC, Corporations, businness, agency, etc.)
Telephone Number: 252-752-2106
Email Address: * [e-mail]
How would you like to received your determination?*
Is there an agent or consultant responsible for the request?*
Yes
No
Attach agent authorization letter: * Executed Agent Authorization - 5-23
44.53KB
23.pdf
PDF only
Agent/Consultant Information
How would you like to receive your USPS
determination letter?* Email
Name of Agent: * Dwight Vernelson
Company Name:* Rivers & Associates, Inc.
Email Address: * [e-mail]
m
Project Information

Has anyone form DWR done a previous site visit?*
Yes
No
Other
Staff Name: Chris Pullinger
Date of Visit: 4/2/2018
Site Information
.....................................................................................................................................................................................................................
Nearest Highway/Street: * Ayden Golf Club Road - NCSR 1723
Nearest Town: * Ayden
Nearest Named Stream:* Swift Creek
River Basin: * Neuse
County:
Pitt
Please attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo.
Click the upload button or drag and drop files here to attach document
Site Quad.pdf 260.74KB
Pdf file type only
TOPO map look up: https://viewer.nationalmap.gov/basic/
Please attach a map of the site indicating project boundaries on the NRCS Soil Survey.
Click the upload button or drag and drop files here to attach document
NRCS Soil Survey Map.pdf 628.55KB
Pdf file type only
Soil Survey Link: https://www.nres.usda.gov/wps/portal/nres/surveylist/soils/survey/state/?stateld=NC
Latitude and Longitude
............................................................................................................................................................................................................................................................................................................................................................................................
Please provide the Latitude and Longitude for physical location for the determination that. If you have a physical
address you can look up the Latitude and Longitude by typing in an address or filling out the information
manually.
Choose below how you would like to provide this information.
Address Lookup
Manually
Latitude:-77.393848
Longitude: 35.456336
Misc attachments: Appvd-Renewed Buffer Call 04-02-18.pdf 3.03MB
Property Access Certification -
395.96K6
Executed_05-16-23. pdf
pdf or kmz file types only
By digitally signing below, I certify that:

• I have given true, accurate, and complete information on this form;
• I agree that submission of this 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 "Determination Request' form."
Signature
Date Submitted: 5/30/2023
Initial Review
ID#* 20080760
Version * 3
Do you want to send for review?* Yes No
Select Reviewer: * Robert Tankard:[e-mail]
Select Regional Office:* Washington Regional Office - [phone]