20201365 Ver 1_Determination Request (4)_20201005

Stream Origin/Buffer Applicability Determination
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:* HL-0081 Old Stage Road (SR 1006)widening from Rock Service
Station Rd to Rolling Meadows Drive(0.5mi)for spot safety project
Is this a transportation project?* C' Yes r No
What type of request is this?* 17 Buffer r IP Stream Determination
r Isolated Wetland r Stream
Check all that apply.
Owner Information
Name on the Recorded Deed:* NC Department of Transportation
Responsible Party: NCDOT DIV 5 Heather W. Montague
(for LLC,Corporations,businness,agency,etc.)
Telephone Number: [phone] cell
How would you like to received your determination?*
r- USPS rJ Email
Email Address:* [e-mail]
Is there an agent or consultant responsible for the request?*
✓ Yes
C' No
Project Information
Has anyone form DWR done a previous site visit?*
✓ Yes
( No
✓ Other
Date of Visit:
Site Information
Nearest Highway/Street:* SR 1006(Old Stage Road)
Nearest Town:* Raleigh
Nearest Named Stream: Little Creek
River Basin:* Neuse
County:*

Wake
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
old stage rd_rock service station_
1.03MB
Feature A topo.pdf
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
old stage rd_rock service station_
1.01MB
Feature A soils.pdf
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.
C' Address Lookup
r Manually
Project Look Up Address: Street Address
9905 Old Stage Road
Address Line 2
City State/Province/Region
Raleigh NC
Fbstal/Zip Code Country
27603-9556 US
Latitude: 35.63900
Longitude: -78.67109
Misc attachments: HL-00081(Wake)Old Stage Rd at Rock
Service Station Rd_soil survey only 404.62KB
feature pictures.pdf
NC DWQ Stream Identification Form
518.69KB
Version 4pointl 1_HL-0081 Wake.pdf
pdf or krre 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
Date Submitted: 10/5/2020
Initial Review
......................................................................................................................................................................................................................................................................................................................................................................................................
ID#* 20201365
Version* 1
Do you want to send for review?* ( Yes r No
Select Reviewer:* Rob Ridings:eads\rgridings
Select Regional Office:* Central Office-[phone]