20200639 Ver 1_Determination Request_20200512

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:*
Broad Street Culvert Replacement
r Yes r No
r% Buffer r IP Stream Determination
r Isolated Wetland r Stream
Check all that apply.
N/A - Town of Carrboro Public Right -of -Way
Responsible Party: Sungate Design Group, PA
(for LLC, Corporations, businness, agency, etc.)
Telephone Number: 919-710-8462
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:* Broad Street
Nearest Town:* Carrboro
Nearest Named Stream:* U/S of Bolin Creek, North of
Tanbark Branch.
River Basin:* Cape Fear
County:*

Orange
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
USGS
19.38MB
NC_Chapel_Hi II_20190805_TM_geo_re...
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.
aick the upload button or drag and drop files here to attach documnt
NRCS Orange Co Soil Map 30.pdf 5.16MB
Rif file type only
Soil Survey Link: https://wwvv.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.
f Address Lookup
r Manually
Latitude: 35.916104
Longitude:-79.068696
Misc attachments: Broad St —Plan View.pdf 771.74KB
NCDEQ Riparian Buffer Areas Map.pdf 339KB
pdf or lqm 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: 5/12/2020
Initial Review
ID#* 20200639
Version* 1
Do you want to send for review?* r Yes r No

Select Reviewer:* Robert Patterson: eads\rd patterson
Select Regional Office:* Central Office - [phone]