B-5318 BufferDeterminationRequestForm

� .STATE
ROY COOPER - n
Governor
�2
MICHAEL S.REGAN ` ,a.n�
Secretary
S.DANIEL SMITH NORTH CARauNA
Director Environmental Quality
Date Received DWR Use Only:Project#
Buffer Determination Request Form
Property Owner Information
1.Owner Information
Ia.Name(s)on Recorded Deed NCDOT Transportation Project
lb.Responsible Party(for LLC)
lc.Mailing Address 2612 North Duke St- Durham,NC 27704
1d.Telephone Number 256159 le.Email Address [e-mail]
Address of Property:9300 Ligon Mill Road,Wake Forest,NC 27587
Project Description(attach plan if available): ):Replacement of Bridge No. 126 on SR 2044(Ligon Mill Rd)over Smith Creek
Consultant/Agent Information
4.Agent/Consultant Information
4a.Name,Company
4b.Mailing address
4c.Telephone no. 4d.Email address
5.Project and Site Information
5a.Name of project B-5318 5b.County Wake
5c.Nearest Named Stream Smith Creek 5d.River Basin Neuse River
6.Has anyone from DWR visited the site? I Y/N Staff Name Date of Visit?
Attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo and/or NRCS Soil Survey.
Please return form Josh Brigham
to: 1628 Mail Service Center
Raleigh,NC 27699-1628
Email:[e-mail]
Please contact the Raleigh Regional Office at(919) 791-4251 if you have any questions.
D E Q� North Carolina Department of Environmental Quality I Division of Water Resources Raleigh Regional Office 4 3800 Barrett Drive I Raleigh,North Carolina 27609
NORTH CAROLINA
0. hMm9�W.—Wo�.ory 919.791.4200