20191486 Ver 1_Determination Request_20191031

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
CMPD Independence Division
r Yes r No
r% Buffer r IP Stream Determination
r% Isolated Wetland rJ Stream
Check all that apply.
Name on the Recorded Deed:* City of Charlotte
Responsible Party: Kathleen Cishek
(for LLC, Corporations, businness, agency, etc.)
Telephone Number: 704-432-5214
How would you like to received your determination?*
F W
Email Address:* [e-mail]
Is there an agent or consultant responsible for the request?
C' Yes
r No
Project Information
Has anyone form DWR done a previous site visit?*
r
Date of Visit:
Site Information
Nearest Highway/Street:* East Independence Blvd
Nearest Town:* Charlotte, NC
Nearest Named Stream:* Campbell Creek
River Basin:* Catawba
County: *

Mecklenburg
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 docurrent
CMPD Vicinity Map 200m 100.pdf 238.35KB
Rif 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 docurrent
CMPD Soils Map 101519.pdf 395.19KB
R1F 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.
r Address Lookup
r Manually
Latitude: 35.180
Longitude:-80.752
Misc attach me nts: pdforlgr 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');
• 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
cl�lf6e�w
Date Submitted: 10/31/2019
Initial Review
D# * 20191486
Version * 1
Do you want to send for review?* r Yes r No
Select Reviewer:* Alan Johnson:eads\adjohnson1

Select Regional Office:* Mooresville Regional Office - [phone]

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Site Coords 35.180' N
NAD83 81.752° W
Vicinity Map
CMPD Independence Division
401/404 CWA Evaluation
Approx Scale 1"=1,000'
Capstone Civil Engineering Inc.
4107 Rose Lake Dr. Ste F
Charlotte, NC 28217
980.938.6770
4capstane
Topozone
Copied from USGS
Charlotte East Quad
Project 400-18-022
Oct 6, 2019

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CMPD Site
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CiaciI Urban Land Complex2to EMslopewelI drained
NCO Helena Sand L oarn 2 to 9% elope low perrneabiIity seasolnal perched water table
G919P Helena Urban Land Complex 2to 9%s1ope, Iow permeability high shrinOwl I
Rf Urban Land-4pical impervious cover
Site Coords 35.180' N AScale 1" = 200' Verified using
NAD83 81.752° W pproxcae Latest USDA soils data J
Soils Map
CMPD Independence Division
401/404 CWA Evaluation
Capstone Civil Engineering Inc.
4107 Rose Lake Dr. Ste F Project 400-18-022
Charlotte, NC 28217
980.938.6770
wPs10ne Oct 14, 2019