20201183 Ver 1_Determination Request_20200910

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:
Fey Reyes
f Yes r No
r Buffer
r Isolated Wetland
Check all that apply.
Fey Reyes
r IP Stream Determination
fJ Stream
(for LLC, Corporations, businness, agency, etc.)
How would you like to received your determination?*
r USPS W Email
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 Yes
r No
r Other
Date of Visit:
Site Information
Nearest Highway/Street:* Hvy 795
Nearest Town:* Goldsboro
Nearest Named Stream:* Smith Mill Run
River Basin:* Neuse
County:*

Wayne
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
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 document
Rif 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.
f Address Lookup
f Manually
Latitude:
Longitude:
M isc attachments: pdf or lace 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');
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:
Initial Review
ID#*
Version*
Do you want to send for review?*
Select Reviewer:*
Select Regional Office:*
G! 15 I-Ljtif6
9/10/2020
20201183
1
r Yes r No
Chris Pullinger:eads\rcpullinger
Washington Regional Office - [phone]