20220345 Ver 1_Pre-JD Request Form_20220314

Jurisdictional Determination Request
M
US Army Corps
of Engineers,
Wiimiington Distrid
This form is intended for use by anyone requesting a jurisdictional determination (JD) from the
U.S. Army Corps of Engineers, Wilmington District (Corps). Please include all supporting
information, as described within each category, with your request. You may submit your request
to the appropriate Corps Field Office (or project manager, if known) via mail, electronic mail, or
facsimile. A current list of county assignments by Field Office and project manager can be
found on-line at: http://www.saw.usace.army.mil/Missions/RegulatoU PermitProgram.asl2x , by
telephoning: 910-251-4633, or by contacting any of the field offices listed below:
ASHEVILLE REGULATORY FIELD OFFICE
US Army Corps of Engineers
151 Patton Avenue, Room 208
Asheville, North Carolina 28801-5006
General Number: [phone]
Fax Number: [phone]
RALEIGH REGULATORY FIELD OFFICE
US Army Corps of Engineers
3331 Heritage Trade Drive, Suite 105
Wake Forest, North Carolina 27587
General Number: [phone]
Fax Number: [phone]
WASHINGTON REGULATORY FIELD OFFICE
US Army Corps of Engineers
2407 West Fifth Street
Washington, North Carolina 27889
General Number: [phone]
Fax Number: [phone]
WILMINGTON REGULATORY FIELD OFFICE
US Army Corps of Engineers
69 Darlington Avenue
Wilmington, North Carolina 28403
General Number: 910-251-4633
Fax Number: [phone]
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Jurisdictional Determination Request
INSTRUCTIONS:
All requestors must complete Parts A, B, C, D, E and F.
NOTE TO CONSULTANTS AND AGENCIES: If you are requesting a JD on behalf of a
paying client or your agency, please note the specific submittal requirements in Part G.
NOTE ON PART D — PROPERTY OWNER AUTHORIZATION: Please be aware that all JD
requests must include the current property owner authorization for the Corps to proceed with the
determination, which may include inspection of the property when necessary. This form must be
signed by the current property owner to be considered a complete request.
NOTE ON PART D - NCDOT REQUESTS: Property owner authorization/notification for JD
requests associated with North Carolina Department of Transportation (NCDOT) projects will be
conducted according to the current NCDOT/USACE protocols.
NOTE TO USDA PROGRAM PARTICIPANTS: A Corps approved or preliminary JD may not
be valid for the wetland conservation provisions of the Food Security Act of 1985. If you or
your tenant are USDA Program participants, or anticipate participation in USDA programs, you
should also request a certified wetland determination from the local office of the Natural
Resources Conservation Service, prior to starting work.
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Jurisdictional Determination Request
A. PARCEL INFORMATION
Street Address: See attached Exhibits
City, State: Rougemont
County: Person
Directions: The new line originates at the Upper Piedmont Landfill and
extends roughly SW for 4.4 miles
Parcel Index Number(s) (PIN): See attached List
B. REQUESTOR INFORMATION
Name:
Mailing Address:
Telephone Number:
Electronic Mail Address 1
Joey Lawler, P.W.S.
2016 Ayrsley Town Blvd., Suite 2A
7904.604.6474
[e-mail]
Select one:
❑ I am the current property owner.
❑✓ I am an Authorized Agent or Environmental Consultant
❑ Interested Buyer or Under Contract to Purchase
❑ Other, please explain.
C. PROPERTY OWNER INFORMATION
Name: Dominion Energy North Carolina (easement only)
Mailing Address: 220 Operation Way, MC C221
Cayce, SC 29033
Telephone Number: 803.201.2539
Electronic Mail Address 3: [e-mail]
❑ Proof of Ownership Attached (e.g. a copy of Deed, County GIS/Parcel/Tax Record data)
1 If available
z Must attach completed Agent Authorization Form
3 If available
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Jurisdictional Determination Request
D. PROPERTY OWNER CERTIFICATION
I, the undersigned, a duly authorized owner of record of the property/properties identified herein,
do authorize representatives of the Wilmington District, U.S. Army Corps of Engineers (Corps)
to enter upon the property herein described for the purpose of conducting on -site investigations
and issuing a determination associated with Waters of the U.S. subject to Federal jurisdiction
under Section 404 of the Clean Water Act and/or Section 10 of the Rivers and Harbors Act of
1899.
See attached Agent Form
Property Owner (please print)
Property Owner Signature
E. JURISDICTIONAL DETERMINATION TYPE
Select One:
Date
❑ I am requesting that the Corps provide a preliminary JD for the property identified herein.
This request does include a delineation.
❑ I am requesting that the Corps provide a preliminary JD for the property identified herein.
This request does NOT include a delineation.
❑ I am requesting that the Corps investigate the property/project area for the presence or
absence of WoUSs and provide an approved JD for the property identified herein. This
request does NOT include a request for a verified delineation.
❑ I am requesting that the Corps delineate the boundaries of all WoUS on a property/project
area and provide an approved JD (this may or may not include a survey plat).
❑ I am requesting that the Corps evaluate and approve a delineation of WoUS (conducted
by others) on a property/project area and provide an approved JD (may or may not
include a survey plat).
4 For NCDOT requests following the current NCDOT/USACE protocols, skip to Part E.
5 Waters of the United States
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Jurisdictional Determination Request
F. ALL REQUESTS
❑ Map of Property or Project Area (attached). This Map must clearly depict the boundaries
of the area of evaluation.
✓❑ Size of Property or Project Area - 26 acres
nI verify that the property (or project) boundaries have recently been surveyed and marked
by a licensed land surveyor OR are otherwise clearly marked or distinguishable.
G. JD REQUESTS FROM CONSULTANTS OR AGENCIES
(1) Preliminary JD Requests:
✓❑ Completed and signed Preliminary Jurisdictional Determination Form6.
�✓ Project Coordinates: 36.298305
Latitude-78.837023
Maps (no larger than l 1x17) with Project Boundary Overlay:
Longitude
❑ Large and small scale maps that depict, at minimum: streets, intersections, towns
✓❑ Aerial Photography of the project area
�✓ USGS Topographic Map
✓❑ Soil Survey Map
❑ Other Maps, as appropriate (e.g. National Wetland Inventory Map, Proposed Site
Plan, previous delineation maps, LIDAR maps, FEMA floodplain maps)
6 See Appendix A of this Form. From Regulatory Guidance Letter No. 08-02, dated June 26, 2008
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Jurisdictional Determination Request
Delineation Information (when applicable):
Wetlands:
❑ Wetland Data Sheets
Tributaries:
❑ USACE Assessment Forms
❑✓ Upland Data Sheets ❑ Other Assessment Forms
(when appropriate)
✓❑ Landscape Photos, if taken
❑� Field Sketch overlain on legible Map that includes:
■ All aquatic resources (for sites with multiple resources, label and identify)
■ Locations of wetland data points and/or tributary assessment reaches
■ Locations of photo stations
■ Approximate acreage/linear footage of aquatic resources
(2) Approved JDs including Verification of a Delineation:
❑ Project Coordinates:
Latitude
Longitude
Maps (no larger than l 1x17) with Project Boundary Overlay:
❑ Large and small scale maps that depict, at minimum: streets, intersections, towns
❑ Aerial Photography of the project area
❑ USGS Topographic Map
❑ Soil Survey Map
❑ Other Maps, as appropriate (e.g. National Wetland Inventory Map, Proposed Site Plan,
previous delineation maps)
1987 Manual Regional Supplements and Data forms can be found at:
http://www.usace.army.mil/Missions/CivilWorks/RegulatoryProgramandPermits/reg supp.aspx
Wetland and Stream Assessment Methodologies can be found at:
http://portal.ncdenr.org/c/document library/get file?uuid=76f3c58b-dab8-4960-ba43-45b7faf06f4c&groupld=38364 and,
http://www.saw.usace.armv.mil/Portals/59/docs/reeulatorv/r)ublicnotices/2013/NCSAM Draft User Manual 130318.pdf
8 Delineation information must include, at minimum, one wetland data sheet for each wetland/community type.
Version: December 2013 Page 6