20220128 Ver 1_Field Map_20220126

ROY COOPER
Governor
ELIZABETH S. BISER
Secretory
DANNY SMITH
Dir
NORTH CAROuNA
EEr4onnnnmlQuadty
Express Buffer Applicability / Stream Origin
Determination Request
CIOr
Property Owner Information
1. Owner Information (corporation/individual who is legally responsible for the property and its compliance)
la. Name(s) on Recorded Deed
419/I/2 y DE4W7 JfO
lb. Responsible Party (for LLC)
lc. Mailing Address
ZZ/ 4-042,07Y Ga.i34-
ld. Telephone Number
7._{2-4/4- jyd9 I le. Email address I deaa-tonioh s6grn4f/'
2. Address of Property or Location of Project Site (including county, nearest named town, and highway or road name/ number):
3000 4,e-57 )ELd Al. Gi .vdicrE N.r. Z7834-
3. Agent I Consultant Information
3a. Agent/ Consultant Name
L£N TOZen
3b. Company
T07W E ,AU/ZQE7ZS /me.
3c. Mailing address
/50-4 E. A-22.e%OG. Nip 4,4fft7114/646A, f: 2659D
3d. Telephone no. 7S2-54/-6-f/" 13e. Email address ILduzc/0,o./, ccw
4. Project / Site Information
4a. Name of project •
4d. River Basin
7-4?
4b. County
yi77"
4e. LatiLong
4c. Nearest Named Stream
Ste Number
Stream Calls
5. Project Description (attach plan if available)
6. Has anyone from DWQ visited the
site?
Y
O
Staff Name:
Date of visit:
7. Does DWR staff have permission to /
access this property? lll///
Y/
N
8. Attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo andlor NRCS Soil Survey
If you are unable to locate either of these maps, please contact the DWR Washington Regional Office for assistance.
DWR Use Only: Is this determination for the purpose of Buffer mitgallon? „Nutrient offset credit?
9. Please
to:
return form Chris Pullinger
943 Washington Square Mall
Washington, NC 27889
Email: Chris.Pullingerrancdenr.00v
Please contact Chris Pullinger at the Washington Regional Office at [phone] id you have any questions.
Note: Submittals on Friday after 12:00 pm
Will be stamped as received on the
Next business day
North Carolina Department of Environmental Quality!Division of Water Resources- Washington Regional Office
943 Washington Square Mall, Washington, Sorts Carolina 23839