Ver _Determination Request_20240126 (2)

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
Name on the Recorded Deed:
Responsible Party :
Telephone Number:
1117 Tarbert Court
Yes No
Yes No
Buffer
Isolated Wetland
Check all that apply.
Debra Haraway and Jennifer Prilliman
(for LLC, Corporations, businness, agency, etc.)
9192720310
Email Address: * [e-mail]
How would you like to received your determination?*
Is there an agent or consultant responsible for the request?*
Yes
No
Project Information
Has anyone form DWR done a previous site visit?*
Yes
No
Other
Staff Name: Danny Smith
Date of Visit: 4/14/2014
Site Information
Nearest Highway/Street:
Nearest Town: *
Nearest Named Stream:*
River Basin: *
Cary Parkway/Lake Pine
Cary
UT To Swift Creek
Neuse
IP Stream Determination
Stream

County: *
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
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
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 Address Lookup
provide this information. Manually
Project Look Up Address: street Address
1117 Tarbert Court
Address Line 2
City
State / Province / Region
Cary
NC
Postal / Zip Code
Country
27511-5060
US
Latitude: 35.7568705
Longitude:-78.8057432
Misc attachments: pdf or kmz file types only
By digitally signing below, I certify that:
o I have given true, accurate, and complete information on this form;
o 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")
o 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
o I intend to electronically sign and submit the "Determination Request' form."
Signature
cY/P�tII yyll tRit'4�1�
Date Submitted: 3/7/2024
Initial Review RRO
.......................................................

Do you want to send this for review? Yes No
D# * 24-080
Select Reviewer: * James Westcott:james.westcott
Select Regional Office: * Raleigh Regional Office - [phone]