OldWakeForestRoad_BufferDetermination (2)

ROY COOPER
Governor
MICHAEL S.REGAN
Secretary
LINDA CULPEPPER
Water Resources Interim Director
ENVIRONMENTAL QUALITY
Date Received DWR Use Only:Project#
Buffer Determination Request Form
Property Owner Information
1.Owner Information
la.Name(s)on Recorded Deed NCDOT
lb.Responsible Party(for LLC) Grady McCollum,P.E.,Senior Engineer,City of Raleigh
lc.Mailing Address One Exchange Plaza,Raleigh,NC 27601
Id.Telephone Number 919-996-3762 le.Email Address [e-mail]
Address of Property:Old Wake Forest Road Raleigh,NC
Project Description(attach plan if available): NCDOT Project(U-6242)Old Wake Forest Road Widening
Consultant/Agent Information
4.Agent/Consultant Information
4a.Name,Company Preston Butler
4b.Mailing address 3040 NC 42 West,Clayton,NC 27520
4c.Telephone no. [phone] 4d.Email address [e-mail]
5.Project and Site Information
5a.Name of project Old Wake Forest Road Widening 5b.County Wake
5c.Nearest Named Stream Perry Creek 5d.River Basin Neuse
6.Has anyone from DWR visited the site? Y/N Staff Name I 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) 791-4200 if you have any questions.
Division of Water Resources,Raleigh Regional Office,Water Quality Operations Section http://portal.ncdenr.org/web/wq/aps
1628 Mail Service Center,Raleigh,NC 27699-1628 Phone: [phone]
Location: 3800 Barrett Drive,Raleigh,NC 27609 Fax: [phone]

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