20230193 Ver 1_Determination Request_20230207

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: * 696 Laurie Ellis Rd - Bofenkamp - Pitt Co Parcel 14642
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: *
Bofenkamp, Jane Mellon & Mellon, Mary F
Responsible Party : Brad Bofenkamp
(for LLC, Corporations, businness, agency, etc.)
Telephone Number: 919-880-8426
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 Information
Has anyone form DWR done a previous site visit?*
Yes
No
Other
Unknown
Date of Visit:
Site Information
Nearest Highway/Street: *
Nearest Town:*
Nearest Named Stream:*
River Basin:*
SE corner of Old Tar Rd & Laurie
Ellis Rd
Winterville
Fork Swamp
Neuse

County: *
Pitt
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
Safari - Feb 7, 2023 at 10_55 AM.pdf 656.53KB
Pdf file type only
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
Safari - Feb 7, 2023 at 11_03 AM 2.pdf 1.17MB
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
Project Look Up Address: Street Address
696 Laurie Ellis Rd
Address Line 2
City State / Province / Region
Winterville NC
Postal / Zip Code Country
28590 USA
Latitude:
Longitude:
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");
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
o I intend to electronically sign and submit the "Determination Request" form."
Signature
B,1143.40
Date Submitted: 2/7/2023

Initial Review
ID#* 20230193
Version* 1
Do you want to send for review? * • Yes No
Select Reviewer: * Robert Tankard:eads\rbtankard
Select Regional Office: * Washington Regional Office - [phone]

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