20200036 Ver 1_Determination Request_20200108

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?*
What type of request is this?*
Owner Information
Name on the Recorded Deed:*
Responsible Party:
Telephone Number:
Kirt Nichols Residence - 111 Kenilworth Rd
r Yes r No
r% Buffer r IP Stream Determination
r Isolated Wetland r Stream
Check all that apply.
Kirt Nichols
pool pro of greenville Ilc
(for LLC, Corporations, businness, agency, etc.)
252-559-3960
How would you like to received your determination?*
1— 141
Email Address:* [e-mail]
Is there an agent or consultant responsible for the request?*
r Yes
r No
Project Information
Has anyone form DWR done a previous site visit?*
r
r
r
Date of Visit:
Site Information
Nearest Highway/Street:* 111 Kenilworth Rd
Nearest Town:* Greenville
Nearest Named Stream:* Fork Swamp
River Basin:* Neuse
County:*

F 1
Please attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo.
aickthe upload button or drag and drop files here to attach document
Kirt USGS.pdf 2.34MB
Ftlr 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.
aick the upload button or drag and drop files here to attach document
Kirt Soil.pdf
Ftlr file type only
4.01 MB
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.
r Address Lookup
f Manually
Project Look Up Address: Street Address
111 Kenilworth Road
Address Line 2
City
Greenville
Rbstal / Zip Code
27858-6308
Latitude: 35.5741954
Longitude:-77.37440960000004
M isc attachments: pdr or lace file types only
By digitally signing below, I certify that:
State / Frovince / Pegion
NC
Country
US
• 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');
o 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:
1 /8/2020
Initial Review

ID#*
Version*
Do you want to send for review?*
Select Reviewer:*
Select Regional Office:*
20200036
r Yes r No
Chris Pullinger:eads\rcpullinger
Washington Regional Office - [phone]

Kirt Nicho l s Resid en ce - 111 Ken i lw orth Rd
2019 USGS Topgraphic Map 1:24 Sc ale for Greenville SE
Legend
111 Kenilworth Rd
500 ft
N➤➤N
Kirt Nicho l s Resid en ce - 111 Ken i lw orth Rd
1974 NRCS Soil Survey of Pitt County Sheet no. 49
Legend
111 Kenilworth Rd
1000 ft
N➤➤N