HomeMy WebLinkAbout20230171 Ver 3_Determination Request_20230714Please 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:* Willow Pond
Is this a transportation project?* Yes No
Is this request for a mitigation site? * ` Yes No
What type of request is this?* C Buffer Q IP Stream Determination
Isolated Wetland Stream
Check all that apply.
Owner Information
Name on the Recorded Deed: * Willow Pond Owners Association, Inc
Responsible Party : Jon Bauman
(for LLC, Corporations, businness, agency, etc.)
Telephone Number: 4806625122
Email Address: * jon.e.bauman@gmail.com
How would you like to received your determination?*
Mailing Address: * Street Address
306 Willow Pond Drive
Address Line 2
City
State / Province / Region
La Grange
NC
Postal / Zip Code
Country
28551
US
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: * US 70 and Beston Road
Nearest Town: * La Grange
Nearest Named Stream:* Mira Branch
River Basin: * Neuse
County: *
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
Screenshot 2023-07-14 at 20.06.20
1.6MB
copy.pdf
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
Screenshot 2023-07-14 at 20.11.25
5.26MB
copy.pdf
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: N 35'18'15.4"
Longitude: W 077°50'53.1"
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;
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: 7/14/2023
Initial Review
.................................................
ID#* 20230171
Version *
Do you want to send for review?* Yes No
Select Reviewer: * Robert Tankard:robert.tankard@ncdenr.gov
Select Regional Office: * Washington Regional Office - (252) 946-6481