20221316 Ver 1_Determination Request_20220926

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: * Wintergreen Telecommunications Tower
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: *
Kathy W. Jarman
Responsible Party : Verizon Wireless
(for LLC, Corporations, businness, agency, etc.)
Telephone Number: 704-510-8604
How would you like to received your determination?*
USPS Email
Email Address: *
[e-mail]
Is there an agent or consultant responsible for the request?*
Attach agent authorization letter:*
Agent/Consultant Information
How would you like to receive your
determination letter?*
Name of Agent: *
Company Name:*
Email Address: *
Project Information
WINTERGREEN Right of Entry
Agreement [fully executed].PDF
PDF only
USPS
Email
Dylan Warren
Terracon Consultants, Inc.
[e-mail]
445.83KB

Has anyone form DWR done a previous site visit?*
Yes
No
Other
Date of Visit:
Site Information
..............................................................
Nearest Highway/Street: *
Nearest Town:*
Nearest Named Stream:*
River Basin:*
County: *
Craven
Jonestown Road
Dover, NC
Flat Swamp
Neuse
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
Topo Map.pdf
Pdf file type only
1.45MB
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 document
NRCS Map.pdf
Pdf file type only
769.3KB
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: 35.2557
Longitude: -77.3298
Misc attachments:
By digitally signing below, I certify that:
pdf or kmz file types only
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");

a I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
a I intend to electronically sign and submit the "Determination Request" form."
Signature
Ofiaor Wastm
Date Submitted:
Initial Review
.....................................................
ID#* 20221316
Version* 1
Do you want to send for review? * • Yes No
Select Reviewer: * Robert Tankard:eads\rbtankard
Select Regional Office: * Washington Regional Office - [phone]
9/26/2022