BufferDetermReqForm-RRO-20221122.docx

Date Received___
DWR Use Only: Project #



Buffer Determination Request Form

Property Owner Information

1. Owner Information

1a. Name(s) on Recorded Deed


1b. Responsible Party (for LLC)


1c. Mailing Address


1d. Telephone Number

1e. Email Address


Address of Property:

Project Description (attach plan if available):





Consultant/Agent Information

4. Agent/Consultant Information

4a. Name, Company


4b. Mailing address


4c. Telephone no.

4d. Email address


5. Project and Site Information

5a. Name of project

5b. County


5c. Nearest Named Stream

5d. River Basin


6. Has anyone from DWR visited the site?
Y / N

Staff Name

Date of Visit?




Attach a map of the site indicating project boundaries on the USGS 1:24,000 Topo and/or NRCS Soil Survey.





Please return form to:

Joe Myers
1628 Mail Service Center
Raleigh, NC 27699-1628
Email: [e-mail]



Please contact the Raleigh Regional Office at [phone] if you have any questions.