20240225 Ver 1_Determination Request_20240207

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
U-4758 (Widen SR 1818 / SR 1850)
Yes No
Yes No
Buffer
Isolated Wetland
Check all that apply.
Name on the Recorded Deed: * NA - NCDOT
Responsible Party :
Robert Crowther
(for LLC, Corporations, businness, agency, etc.)
Telephone Number:
8047612455
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: * Johnson Street (SR 1818)
Nearest Town: * High Point
Nearest Named Stream:* West Fork Deep River
River Basin: * Cape Fear
IP Stream Determination
Stream

County: *
Guilford
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
U4758_Figure1_USGS.pdf 3.11 MB
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
U4758_Figure2_NRCS.pdf 3.53MB
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: 36.044606
Longitude:-80.017166
Misc attachments: U4758 Buffer Determination Request
14.19MB
Supplemntal Info.pdf
pdf or kmz file types only
By digitally signing below, I certify that:
d I have given true, accurate, and complete information on this form;
• 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")
• 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');
• I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
• I intend to electronically sign and submit the "Determination Request' form."
Signature
Date Submitted: 2/7/2024
Initial Review
ID#* 20240225
Version * 1

Do you want to send for review? * Yes No
Select Reviewer: * Ryan Conchilla:ryan.conchilla
Select Regional Office:* Central Office - [phone]