20230628 Ver 1_Determination Request_20230428

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:*
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:
503 Windley
Yes No
Yes No
Buffer
Isolated Wetland
Check all that apply.
Sean Sprouse
(for LLC, Corporations, businness, agency, etc.)
6143610885
Email Address: * [e-mail]
How would you like to received your determination?*
Is there an agent or consultant responsible for the request?*
Yes
No
Project Information
Has anyone form DWR done a previous site visit?*
Yes
No
Other
Date of Visit:
Site Information
Nearest Highway/Street: *
503 Windley Rod
Nearest Town: *
Washington
Nearest Named Stream:*
Cherry Run
River Basin: *
Tar -Pamlico
IP Stream Determination
Stream

County: *
Beaufort
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
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
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:
Longitude:
Misc attachments: 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;
d 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');
d 1 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
c-5e',7.Y totA1eJ!
Date Submitted: 4/28/2023
Initial Review
ID#* 20230628
Version * 1
Do you want to send for review?* Yes No
Select Reviewer: * Robert Tankard:[e-mail]
Select Regional Office: * Washington Regional Office - [phone]