20220139 Ver 1_Determination Request_20220113

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: * Privott Property
Is this a transportation project?* Yes No
Is this request for a mitigation site?* Yes No
What type of request is this?* Buffer IP Stream Determination
Isolated Wetland Stream
Check all that apply.
Owner Information
Name on the Recorded Deed: * Privott Michael Warrick
Responsible Party : Water & Land Solutions, LLC
(for LLC, Corporations, businness, agency, etc.)
Telephone Number: 9196325910
How would you like to received your determination?*
USPS Email
Email Address: * [e-mail]
Is there an agent or consultant responsible for the request?*
Project li
Has anyone form DWR done a previous site visit?*
Yes
No
Other
Date of Visit:
Site Information
Nearest Highway/Street: *
Adler Ln
Nearest Town: *
Goldsboro
Nearest Named Stream: *
Hooks Mill Creek
River Basin: *
Neuse

County: *
Wayne
Please attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo.
Click the upload button or drag and drop files here to attach document
Privott_Property - USGS Topo.pdf 1.37MB
Pdf file type only
TOPO map look up: https:Hviewer.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 document
Privott_Property - NRCS Soils Map.pdf 951.87KB
Pdf 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.
Address Lookup
Manually
Latitude: 35.456332
Longitude:-77.994253
Misc attachments: pdf or kmz file types only
By digitally signing below, I certify that:
o 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")
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
• I intend to electronically sign and submit the "Determination Request' form."
Signature
Date Submitted: 1/13/2022
Initial Review
ID#* 20220139
Version * 1
Do you want to send for review?* Yes No
Select Reviewer:* Shelton Sullivan:eads\sosullivan

Select Regional Office:* Central Office - [phone]

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