09053_ChowanVeneer_Receptor Survey_20051114

NOV.14.2005 1:09PM
NO.566 P.1
woo 10*�.
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Branch Address:
Sou�hC.rvJ ,JAR71�
SINCE 1901
Phone:( adza 9q3-g/7-s Lax,( AS2) ?V3 -.Ryil2-
d Moar>!� Ne. vFNZ 3)wnn'
To: 5, #u r� Company:
Fax Number: I g - 7 �r 56os l
9 Number of Pages 11
(Including Cover):
From: _a ;; m 11,1c,k s o I j Date & Time: A f oy' mbey, 14 aoo S
S AM
Comments
Ch *WA nJ V YUC- .YL C.O-, pAV-0%�
rOuuN.�►�La� 'A2ac..+ 4&ceplov Sv
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privileged, confidential, or otherwise protected from disclosure. Any review, dissemination, or use of this transmission
or its contents by persons other than the Addressee is strictly prohibited.
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original to us at the above address. Thank You.
I05-20000 (6/97)

NOV.14.2005 1:09PM
Noft CUOMO .
Depadmem of Environment
and N*I ual Rftourtes
NO.566 P.2
Page 1 of 4
BROWNFIELDS AREA RECONNAISSANCE AND RECEPTOR SUR'VEYiGUIDANCE FORM
This form was created to clirify and simplify preparing'a receptor survey for a brownfield site. The form was designed to
minimize unnecessary delays in processing brownfreld applications. This is a guidanee.doeument only and Potential
Developers may complete and submit their own receptor survey, if they desire.
General Instructions
1.) Complete "Property Characteristics Section and all portions of other sections where an "X" has been placed
in the far leftcolumn under "Applicable to Site," as determined by the DENR Brownfields Project Manager
on a site specific basis.
2.) The search -radius distances to potential receptors from the Property boundary will be determined by the
DENR Brownfields Project Managenon a site by site basis.
3,) Search -radius distances are measured from the site Property Boundary unless otherwise indicated by the
DENR Browafield's Project Manager.
Site:
Address:
City:
County: C1,11 Q,W.4,%J 0-00 A-% t!1
Property Characteristics
Provide Infomiation for the following potential receptors
Current Usage
Proposed Usage
Size of Property (acres)
.,Z E
J •$- cAs.S
of property that is wooded
To of property that is scrub/ shrub
% of property that is open land
61) +Jo
% of property that is grass area
y 7ci
% of property that is agricultural crops
o
% of property that is barren
0 % _
90 of property that is used for cominercial or industrial usage
including paved areas
a �10
Surrounding Properties
4ppjicob7cto Site
Surrounding Properties
Current Usage
Proposed Usage
(DENR Uar Orly)
, Zonin&land use
x
North
ae i oti�4,L
X
South.
�(
East
e s r a a,_�1A L
t at V_AJ r
X
West
I r
dP a �
Rev.06/05/02
` a

NOV.14.2005 1:09PM
Nora cir dinar
Departmeot Of Einr►it tiih� tt!
CDM arl d, Natural Ruources
NO.566 . P.3
Page 2 of 4
Potential Receptors - include depth"to top,*construction material and diavieter of the utilities, if available
=eon �
Provide Information for the:,
following potential receptors
YIN
Field
Verified
bate
Verified
Distance, Direction,
Depth
Complete and attach neap as
appropriate
Is a basement or subsurface.'
X
foundation within 500 ft of the
N
Property boundary?.
Is a school,or daycare center
X
within 1000 ft of the Property
N
boundary? v
1s a storm sewer within 100 ft of
X
the Property boundary?
N
Is a sanitary sewer within 100 ft
X .
of the Property boundary?
�(
1
GO
W-sr
r.
Is a septic system leach field ;
X
within 500 ft of the Properly`
(�(
boundary?,
,
Is a water line main within 100 ft
X '
of Property boundary?
Y
G�
was'r
/d1 t
Is a natural gas line'main within
X
100 ft of the Property boundary?
Is a buried telephone/ cable in
X
within 100 ft: of the Property
boundary?
Is a buried electrical cable,main
;
X
wrthin 100 ft of Property
AI
boundary?
Local Water Supply
Public: E de N fo tU Private:.
Potable Water upplier Name: "
Potable Water Supply Source:
Distance; Direction:
Potable Water Source Intake: 1;U41
Distance: ,M Direction:
4
Rev.06/05/0')

NOV:14.2OO5 1:1OPM,
North dCarolina
ospatttment of EnVlrorirftd �t
N� and Naturat Resotrmes
Water supply wells
NO.566 P.4
Page 3 of 4
npplkablstp$;ep
-Provide lnforma'tion for the
Field,
Date
Distance
I Direction
I Depth
Complete and attach map gs
MENtlr#poplyj
following potenti T receptors
'
Verified
Verified
appropriate
Is a public water supply well
f.
�(
within 1 mile of the Property '
Y
1
r,
NORboundary?
Is a private water supply well
X
within 1/2 mile of the'Property
N
boundary?
Is a irrigation supply well within
X
1/2 mile of the Property
N'
boundary?
Is a monitoring well within 1500
X
ft of, the, Property,boundary?
Water Bodies on Property
App7hobletp.Me
fDY?M Upe Oak)
' Provide Information for the .
following potential receptors .
Comment$,
Is water body naturally
X
developed or man made?
AI
MAN mC_
List the uses of the water body
X
s
What is the source of the water
)(
for the water. body ,:,
'R/4)11i hl%.4jZ12.
Wbat is the nature of the bottom
X
of the water body (e.g., rocky or
concrete bottom, drainage ways
or impoundments)
Are there any wetlands present
X
on the property?
NO
Rev. 061051M

NOV.14.2005 1:10PM NO.566 P.5
i
North i arWina Page 4 of 4
bept"entof rlrnnmerrt
Nit and Natural Rmurces
Surface Water Body
,spprrfautgto sue
Provide information for the
Distance I Direct -ion Depth
Complete and attach map as
fnFNRu��+r
following potential receptors
YIN
Name
Type
appropriate
Are there surface waters located
X
within 500 ft of the Property
I
1 v
.boundary?
Additional wabr bodies, if needed
Additional Requests/ Observations
AppAcabletoSite Provide luformation for the Comments
Wv ' 011'10 following potential receptors
Rev.06/05/02

NOV.14.r2005
1:10PM
N0.566 P.6
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"NOV.14.2005 1:11PM
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