20220516 Ver 1_Buffer and/or Stream Determination Request_20220401

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
DANNY SMITH
Director
NORTH CARCLINA
Eil kronwen to! Quality
Express Buffer Applicability / Stream Origin
Determination Request
Property Owner Information
1. Owner Information (corporation/individual who is legally responsible for the property and its compliance)
1 a. Name(s) on Recorded Deed
Tracie Adams
1 b. Responsible Party (for LLC)
1c. Mailing Address
6636 Hwy 43 S., Greenville, NC 27858
1d. Telephone Number
1e. Email address
2. Address of Property or Location of Project Site (including county, nearest named town, and highway or road name/ number):
0 Poker House rd., Grimesland. On the west side of Poker House rd., 300' north of the intersection with Grimesland Bridge Rd.
3. Agent / Consultant Information
3a. Agent/ Consultant Name
Kevin C Martin
3b. Company
Soil & Environmental Consultants, PA
3c. Mailing address
8412 Falls of Neuse Rd., Ste. 204, Raleigh, NC 27615
3d. Telephone no.
919-270-7941
3e. Email address
[e-mail]
4. Project / Site Information
4a. Name of project
NA
4d. River Basin
Tar - Pamlico
4b. County
Pitt
4e. Lat/Long
35.572064 -77.184322
4c. Nearest Named Stream
Chicod Creek
4F. Number
Stream Calls
2
5. Project Description (attach plan if available)
6. Has anyone from DWQ visited the
site?
Y
N
Staff Name:
date of visit:
7. Does DWR staff have permission to
access this property?
Y
N
8. Attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo and/or 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 mitigation? Nutrient offset credit?
9. Please return form
to:
Chris Pullinger
943 Washington Square Mall
Washington, NC 27889
Email: [e-mail]
Please contact Chris Pullinger at the Washington Regional Office at [phone] if 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, North Carolina 27889
252-946-6481

a
C Center for Geographic Information & Analys&
Project Number:
15179.W1
Project Manager:
KM
Scale:
1"=500'
Map Title:
Figure 2 - Soil Survey Map
Poker House Rd.
Pitt County, NC
Date:
03/04/2022
Source:
Soil Survey Sheet No. 44 & 52
0
500 1,000
Feet
Soil & Environmental Consultants, PA
8412 Falls of Neuse Road, Suite 104, Raleigh, NC 27615 • Phone: [phone] • Fax: [phone]
sandee.com

Project Number:
15179.W1
Project Manager:
KM
Scale: 1 1000'
Date:
03/04/2022
Map Title:
Figure 1 - USGS Map
Poker House Rd.
Pitt County, NC
Source:
Grimesland Quadrangle
0 1,000 2,000
1 1 1 1 1 1
Feet
Soil & Environmental Consultants, PA
8412 Falls of Neuse Road, Suite 104, Raleigh, NC 27615 • Phone: [phone] • Fax: [phone]
sandee.com

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
DANNY SMITH.
Director
NORTH CAROLINA
EnrtrolninesztaI Quay
SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION; 36.68 acres as shown on map entitled "Survey for Jake Carl Adams
Jr." prepared by Bjerkeset Land Surveying.
LOT NO. N/A PLAN NO. 86-9 PARCEL ID: 86595
STREET ADDRESS: 0 Poker House Road, Grimesland, NC 27837
Please print:
Property Owner: Tracie Adams
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
-Toisnot Soil & Environmental Consultants_ PA
(Contractor / Agent) 1 (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
6636 Way 43 S. Greenville NC 27858
Telephone:
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Tracie Adams
Authorized Print Name Authorize Signature
Date. + Date: 31)5 34*-
�. 02 ,
R
North Carolina Department of Environmental Quality (Division of Water Resources - Washington Regional Office
943 Washington Square Mall, Washington, North Carolina 27889
252-946-6481