23-350 Field Notes

ROY COOPER
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EL"ETH S. BISER
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RICHARD E. ROGERS, JR.
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NORTH CAROLINA
En onwnlaf QVaWy
Date Received] 7r/zf I DWR Use Only: Project # 25 -3�-D
Buffer Determination Request Form
Property Owner Information
1.Owner Information
[a. Name(s) on Recorded Deed o h Y U O► t g
Ib. Responsible Party (for LLC) 1Z. )YU c K
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Ic. Mailing Address QO) tL[ u101' �t C ar�i��
Id. Telephone Number le. Email Address �NrQ
Address of Property: j Z L11 Q-A�� ol pl N 6. Z 71�7Q 4
Project Description (attach plan if available); /V e C- A a m d e -fer--LAj o v� SuY VC V
Consultant/Agent Information
4. Agent/Consultant Information
4a. Name, Company
4b. Mailing address
4c. Telephone no.
4d. Email address
5. Project and Site Information
Sa. Name of project
5211 Red Mill Road Sb. County Durham
Neuse River/ Falls Lake 5d. River Basin Neuse River/Falls Lake
5c. Nearest Named Stream
6. Has anyone from DWR visited the site? Y / N Staff Name Date of Visit?
Affach a map of the site indicating project Doundaries on me opo anUMMus Sollurvey.
ce Myers
Please return form 1628 Mail Service Center
to: Raleigh, NC 27699-1628
Email:
[e-mail]
Please contact the Raleigh Regional Office at [phone] if you have any questions.
North Caroline Department of Environmental Quality I Dtws+on of Winer Resourca
$12 North SWisbury Street 1 1617 Mul Semxe Cents I RaIngh, North Caroline 27699-1617
919 707 9000
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