Ver _Determination Request (6)_20241003

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
Smithfield Property - Ed Broadhurst
Yes No
Yes No
Buffer
Isolated Wetland
Check all that apply.
IP Stream Determination
Stream
Name on the Recorded Deed: * BROADHURST, JJ HEIRS, BROADHURST, EB
Responsible Party : None
(for LLC, Corporations, businness, agency, etc.)
Telephone Number: 910-264-1075
Email Address: * [e-mail]
How would you like to received your determination?*
Is there an agent or consultant responsible for the request?*
Yes
No
Attach agent authorization letter: * Signed Agent Authorization form
1.02M6
2024.094. pdf
PDF only
Agent/Consultant Information
How would you like to receive your USPS
determination letter?* Email
Name of Agent: * Sean Clark
Company Name:* Sage Ecological
Email Address: * [e-mail]
n

Has anyone form DWR done a previous site visit?*
Yes
No
Other
Date of Visit:
Site Information
Nearest Highway/Street: * N. Brightleaf Blvd
Nearest Town: * Smithfield, NC
Nearest Named Stream:* UT Buffalo Creek
River Basin: * Neuse
County: *
Johnston
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
Figure 1_USGS_Topo_Map.pdf 2.3MB
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
Figure2_NRCS_Soils_Map.pdf 2.85MB
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 Address Lookup
provide this information. Manually
Latitude: 35.5119
Longitude:-78.3292
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');

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
0 t10 06-0
Date Submitted: 10/14/2024
Initial Review RRO
Do you want to send this for review? Yes No
D# * 24-363
Select Reviewer: * Kevin Fowler: kevi n.fowler
Select Regional Office: * Raleigh Regional Office - [phone]