20201983 Ver 1_Determination Request_20201214

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:* Ayden District Park -Dog Park
Is this a transportation project?* f Yes r No
Is this request for a mitigation site? * r Yes r No
What type of request is this?* F Buffer IP Stream Determination
F Isolated Wetland rJ Stream
Check all that apply.
Owner Information
Name on the Recorded Deed:* Town of Ayden
Responsible Party: Town of Ayden
(for LLC, Corporations, businness, agency, etc.)
Telephone Number: 252-481-5837
How would you like to received your determination?*
F I1W
Email Address:* [e-mail]
Is there an agent or consultant responsible for the request?*
C
r
Has anyone form DWR done a previous site visit?*
C
c:
C
Date of Visit:
Site Information
Nearest Highway/Street:*
NC Hwy 11
Nearest Town:*
Ayden
Nearest Named Stream:*
Swift Creek
River Basin:*
Neuse

County:*
Please attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo.
nick the upload button or drag and drop files here to attach docurrent
District Park Topo.pdf 58.44KB
NC_Ayden_20190722_TM.pdf 2.99MB
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 docurrent
Ayden District Park Soil Map 2 -
104.43KB
converted.pdf
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.
r Address Lookup
f Manually
Project Look Up Address: Street Address
3869 Jolly Road
Address Line 2
city State / Frovince / Region
Ayden NC
Rbstal / Zip Code Country
28513 US
Latitude: 35.4884703
Longitude:-77.4229245
M isc attachments: pdf or kne 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:
12/14/2020
Initial Review
ID#*
Version*
Do you want to send for review?*
Select Reviewer:*
Select Regional Office:*
20201983
a Yes () No
Chris Pull inger:eads\rcpullinger
Washington Regional Office - [phone]

�.L ��
_ ��
�!�
��-
.`
.� _- �
_--. - � �
_ � � �
.. � .-- � �
__ -! � �
-.. --�-
.� � - - � �
-�
_ � __

I yA k /
N-B
F4
li
'VA