HomeMy WebLinkAbout20230482 Ver 1_Determination Request_20230330Please 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:*
Is this a transportation project?*
Is this request for a mitigation site?
What type of request is this?*
Owner Information
Name on the Recorded Deed:
Responsible Party :
Telephone Number:
Circle K Goldsboro
Yes No
Yes No
Buffer
Isolated Wetland
Check all that apply.
Circle K Stores Inc.
(for LLC, Corporations, businness, agency, etc.)
Email Address: * apriolo@circlek.com
How would you like to received your determination?*
Name on the Recorded Deed:
Responsible Party :
Telephone Number:
IP Stream Determination
Stream
Wooten Oil and Fuel Company (Wooten Development Co.)
(for LLC, Corporations, businness, agency, etc.)
Email Address: * dwooten@kmsnc.com
How would you like to received your determination?
USPS Email
Name on the Recorded Deed: * Wilson Woodrow Jr.
Responsible Party : (for LLC, Corporations, businness, agency, etc.)
Telephone Number:
Email Address: * woodywilsonl947@outlook.com
How would you like to received your determination?*
Is there an agent or consultant responsible for the request?*
Attach agent authorization letter: *
Circle K_Agent Authorization and Property
230.13KB
Owner Authorization_signed.pdf
Agent/Consultant Information
Wilson —Agent Authorization and Property
981.46K6
Owner Authorization_signed.pdf
Wooten Oil Co —Agent Authorization and
71.68KB
Property Owner Authorization_signed.pdf
PDF only
How would you like to receive your USPS
determination letter?* Email
Name of Agent: * Kate Hefner
Company Name:* Timmons Group
Email Address: * kate.hefner@timmons.com
n
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: *
Arlington Bridge Road
Goldsboro, NC
Neuse River
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
Figure 1 - VIC DWR.pdf 568.06KB
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
Figure 5 - NRCS DWR.pdf 426.53KB
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: 35.350429
Longitude:-78.016332
Misc attachments: 2023.03.30 Circle K Goldsboro BD
4.83MB
Request Package_FINAL (reduced).pdf
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;
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
Date Submitted:
Initial Review
.................................................................................................................
ID#*
Version
Do you want to send for review?
Select Reviewer: *
Select Regional Office:*
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3/30/2023
20230482
1
Yes No
Robert Tankard:robert.tankard@ncdenr.gov
Washington Regional Office - (252) 946-6481