20211009 Ver 1_Determination Request_20210618

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:* W-5705H intersection improvements
Is this a transportation project?* C' Yes r No
Is this request for a mitigation site?* f Yes C' 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:* NCDOT
Responsible Party: Heather W. Montague
(for LLC,Corporations,businness,agency,etc.)
Telephone Number: [phone]
How would you like to received your determination?*
I— I�
Email Address:* [e-mail]
Is there an agent or consultant responsible for the request?*
r
Project Information
....................................................................................................................................
Has anyone form DWR done a previous site visit?*
Date of Visit:
Site Information
Nearest Highway/Street:* SR 2506(Major Slade Rd)
Nearest Town:* Knightdale
Nearest Named Stream:* Poplar Creek
River Basin:* Neuse

County:*
Wake
Please attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo.
Gick the upload button or drag and drop files here to attach docurrent
W-5705H Wake Topo Map.pdf 705.72KB
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
W-5705H Wake Soil Map.pdf 196.72KB
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
C' Manually
Latitude: 35.73653
Longitude: -78.44504
Misc attachments: NCDWQ Stream Identification Form W-
167.18KB
5705H Major Slade Rd Wake.pdf
W-5705H Pictures.pdf 973.19KB
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
w 4.400 460E
Date Submitted: 6/18/2021
Initial Review
ID#* 20211009
Version* 1

Do you want to send for review?* C' Yes r No
Select Reviewer:* Rob Ridings:eads\rgridings
Select Regional Office:* Central Office-[phone]