19941018 Ver 1_Complete File_19941028

State of North Carolina
Department of Environment,
Health and Natural Resources
Division of Environmental Management
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
APPROVAL of 401 Water Quality Certification
Mr. C. R. Styles
NC DOT
P.O. Box 250
Bryson City, N.C. 28713
Dear Mr. Styles:
Al I FA
wook
11? EHN1=1
November 1, 1994
Jackson County
DEM Project # 941018
FIL E
You have our approval to place fill material in 0.02 acres of wetlands or waters for the purpose
of road maintenance at SR 1456, as you described in your application dated 24 October 1994. After
reviewing your application, we have decided that this fill is covered by General Water Quality
Certification Number 2732. This certification allows you to use Nationwide Permit Number 14 when it
is issued by the Corps of Engineers.
This approval is only valid for the purpose and design that you described in your application. If
you change your project, you must notify us and you may be required to send us a new application.
For this approval to be valid, you must follow the conditions listed in the attached certification. In
addition, you should get any other federal, state or local permits before you go ahead with your
project.
If you do not accept any of the conditions of this certification, you may ask for an adjudicatory
hearing. You must act within 30 days of the date that you receive this letter. To ask for a hearing,
send a written petition which conforms to Chapter 150B of the North Carolina General Statutes to the
Office of Administrative Hearings, P.O. Box 27447, Raleigh, N.C. 276 1 1-7447. This certification and
its conditions are final and binding unless you ask for a hearing.
This letter completes the review of the Division of Environmental Management under Section 401
of the Clean Water Act. If you have any questions, please telephone John Domey at 919-733-1786.
Sincerely,
ston Ho d, Jr. P. .
Attachment
cc: Wilmington District Corps of Engineers
Corps of Engineers Asheville Field Office
Asheville DEM Regional Office
Mr. John Domey
Central Files
941018.1tr
P.O. Box 29535, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post-consumer paper

?Ty asWfo e 9 /
- 8 1 k z
i!Af ; i ! S Gib Eery
LNW11:0 Nifi mu ornr??..:
STATE OF NORTH CAROLINA
DEPARTMENT OF TkANsPORTATION
JAMES B. HUNT, JR.
GOVERNOR
DIVISION OF HIGHWAYS
R. SAMUEL HUNT III
SECRETARY
Jackson County
SR 1456
Mr. Bob Johnson
215 Army Corps of Engineer
Reg. Field Office
Room 75, Grove Park Ave.
Asheville, NC 28801-2714
Dear Mr. Johnson,
Bryson City, NC 28713
October 24, 1994
G3"SS% TO
The North Carolina Department of Transportation is proposing to grade, drain, base and
pave primarily along the existing roadway of SR 1456, Addie Mine Road, in Jackson County. In
order to construct this project in accordance with our current secondary road standards and due to the
proximity of Ochre Hr31 Creek and its tributaries, (DEM Class C ) and replacement of three pipe
culverts, we are requesting authorization under Section 404 of the Clean Water Act.
I am sending a straight line diagram with our proposed erosion control and construction
limits at various sites along this project. In addition a typical section of the road, cross sections,
drawings for pipe culvert replacements, general notes and standards on erosion control measures and
a marked county map are enclosed.
The best management practices will be used to minimize and control sedimentation and
erosion on this project. The construction foreman will review all erosion control measures daily to
ensure sedimentation and erosion controls are being effectively controlled. If the planned devices
are not functioning as intended, they will immediately be replaced with better devices. The silt fences
and other erosion control devices will be in place prior to pipe construction and will remain in place
until the project is stabilized. `
By copy of this letter I am asking Mr. David Yowe, North Carolina Resources Commission,
District Fisheries Biologist to comment directly to you concerning the 404 Nationwide permit request.

Mr. Bob Johnson
Page 2
October 24, 1994
Also by copy of this letter, I am requesting authorization to proceed under Section 401 of the
Clean Water Act from Division of Environmental Management.
We would lice to begin construction as soon as possible. N further information is required,
please advise. Your early review and consideration will be appreciated.
Yours truly,
?I!r
C. R. Styles,D
District Engineer
CRS/wmt
cc: Mr. Richard Phillips, P. E., Regional Engineer DEHNR
Mr. F. D. Martin, P. E., Division Engineer
Mr. E. L. Ingle, Area Roadside Environmental Engineer
Mr. Eric Galamb, Water Quality Certification Unit, DEM
Mr. David Yowe, District Fisheries Biologist, NCWRC
NOTIFICATION FORM
INFORMATION SHEET
Nationwide permits that require notification to the Corps of Engineers
Nationwide permits that require, application for Section 401 certification
A. NOTIFICATION.TO THE CORPS OF ENGINEERS DISTRICT ENGINEER. (REFER TO
ITEM B. BELOW FOR DIVISION OF ENVIRONMENTAL MANAGEMENT APPLICATION RE.
QUIREMENTS AND SPECIFICALLY NOTE NWP 26 DIFFERENCE.)
Certain nationwide permits require notification to the Corps of Engineers before work can proceed. They are as follows:
NWP 5 (only for discharges of 10 to 25 cubic yards)
NWP 7
NWP 13 (only for stabilization activities in excess of 500 feet in length or greater-than an average of one cubic yard
per running foot)
NWP 14 (only for fills in special aquatic sites, including wetlands, and must include a delineation of affected special
aquatic sites)
NWP 17
NWP 18 (required when discharge exceeds 10 cubic yards or the discharge is in a special aquatic site and must include
a delineation of the affected special aquatic site, including wetlands)
NWP 21 (must include a delineation of affected special aquatic sites, including wetlands)
NWP 26 (only for greater than .1 acre total impacts and must include a delineation of affected special aquatic sites,
including wetlands)
NWP 33 (must include a restoration plan of reasonable measures to avoid and minimize impacts to aquatic resources)
NWP 37
NWP 38 (must include a delineation of affected special aquatic sites, including wetlands)
For activities that may be authorized by the above listed nationwide permits that require notification, the
applicant shall not begin work
a. Until notified that the work may proceed under the nationwide permit with any special conditions imposed by
the District Engineer, or
b. If notified that an individual permit may be required, or
c. Unless 30 days (calendar) have passed from the time a complete notification is received by the District Engineer
and no notice has been received from the District Engineer, and required state approvals have been obtained.
Required state approvals include: 1) a Section 401 water quality certification if authorization is requested for a
discharge of dredged or fill material, and 2) an approved coastal zone management consistency determination if
the activity will affect the coastal area.
Use of NWP 12 also requires notification to the District Engineer, but work may not begin until written
concurrence is received from the District Engineer. The time periods described above do not apply.
Furthermore, requirements to notify the U.S. Fish and Wildlife Service (USFWS), the National Marine
Fusheries Service (NMFS), and the State Historic Preservation Office (SHPO), as indicated below and on the
- I, ification form, do not apply.
ld. APPLICATION TO DEM FOR NATIONWIDE PERMIT SECTION 401 CERTIFICATION.
Certain nationwide permits require an application to DEM in order to obtain Section 401 water quality certification.
They are NWP 6, NWP 12, NWP 15, NWP 16, NWP 17, NWP 21, NWP 33,NWP 34, NWP-38, and NWP 40.
Certaiii nationwide permits were issued general certifications and require no application. They are NWP 3, NWP 4,
NWF 5, NWP 7, NWP 20, NWP 22, NWP 23".(requires notification to DEM), NWP 25, NWP 27, NWP 32, NWP 36,
and NWP 37.
The following nationwide permits were issued general certifications for only limited activities: NWP 13 (for projects
less than 500 feet in length), NWP 14 (for p%lects that impact waters only), NWP 18 (for projects with less than 10
cubic yards of fill in waters only), and NWP 26 (for projects with less than or equal to one-third acre fill of waters or
wetlands). Projects that do not meet these criteria require application for Section 401 water quality certifications.

C. NOIMCATION/APPLICATION PROCEDURES. ?z
The attached form should be used to obtain approval from the Corps of Engineers and/or the N.C. Divition of
Environmental Management as specified above. The permittee should make sure that all necessary information is
provided in order to avoid delays. One copy of the completed form is required by the Corps of Engineers and seven
copies are required by DEM. Plans and maps must be on 81/2 x II inch paper.
Endangered species requirement: For Corps of Engineers notifications only, applicants must notify the U.S. Fish and
Wildlife Service and/or the National Marine Fisheries Service regarding the presence of endangered species that may
be affected by the proposed project.
U.S. FISH AND WILDLIFE SERVICE' NATIONAL MARINE FISHERIES SERVICE
RALEIGH FIELD OFFICE HABITAT CONSERVATION DIVISION
P.O. Box 33726 - Pivers Island
Raleigh, NC 27636-3726 Beaufort, NC 28516
Telephone [phone] Telephone [phone]
Historic resources requirement: For Corps of Engineers notifications only, applicants must notify the State Historic
Preservation Office regarding the presence of historic properties that may be affected by the proposed project.
STATE HISTORIC PRESERVATION OFFICE
N.C. DIVISION OF ARCHIVES AND HISTORY
109 East Jones Street
Raleigh, NC 27601
Telephone [phone]
Information obtained from these agencies should be forwarded to the Corps.

Devi ID: ACTION ID: AP11 ICI IFiI
Nationwide Permit Requested (Provide Nationwide Permit ft _ 14
JOINT FORM FOR
Nationwide permits that require notification to the Corps of Engineers
Nationwide permits that require application for Section 401 certification
WILMINGTON DISTRICT ENGINEER WATER QUALITY PLANNING
CORPS OF ENGINEERS DIVISION OF ENVIRONMENTAL MANAGEMENT
DEPARTMENT OF THE ARMY NC DEPARTMENT OF ENVIRONMENT, HEALTH,
P.O. Box 1890 AND NATURAL RESOURCES
Wilmington, NC 28402-1890 P.O. Box 29535
ATTN: CESAW CO-E Radleigh, NC 27626-0535
Telephone [phone] AI'TN: MR JOHN DORNEY.
Telephone [phone]
ONE (1) COPY OF THIS COMPLETED APPLICATION SHOULD BE SENT TO THE CORPS OF ENGINEERS.
SEVEN (7) COPIES SHOULD BE SENT TO THE N.C. DIVISION OF ENVIRONMENTAL MANAGEMENT.
PLEASE PRW.
1. Owners Name: North Carolina Department."of Transportation
2. OwnersAddr=:P•O. BOX 250, Bryson City, NC 28713
3. Owners Phone Number (Home): (Work): .[phone]
4, If Applicable: Agent's name or responsible corporate official, address, phone numb=
C. R. Styles
5. Location of work (MUST ATTACH MAP). County: Jackson
Nearest Town or City: Sylva
Specific Location'(Include road numbers, landmarks, etc.): SR 1456, Addie Mine Road
6. Name of Closest Stream/River. Ochre Hill Creek
7. River Basin: Little Tennessee River
8. Is this project located in a watershed classified as Trout, SA, HQW, ORW, WS I, or WS H? YES (X] NO [ ]
9. Have any Section 404 permits been previously requested for use on this property? YES [ ] NO 91
If yes, explain.
10. Estimated total number of acres of waters of the U.S., including wetlands, located on project site:
11. Number of awes of waters of the U.S., including wetlands, impacted by the proposed project:
Filled: - 0.0.2 _ Ac
Drained
Flooded:
Excavated:
Total Impacted: 0.02 Ac

12. Description of proposed work (Attach PLANS-81/2" X 11." .drawings only): To widen and .
pave SR 1456 to meet current NC DOT.standardp,.. _
13. Purpose of proposed work:_ Same q g, hove
14. State reasons why the applicant believes that this activity must be carried out in wetlands. Also, note measures
taken to minimize wetland impacts.
15. You are required to contact the U.S. Fish and Wildlife Service (USFWS) and/or National Marine.Fisheries Service
(NMFS) regarding the presence or any Federally listed orproposed for listing endangered or threatened species or critical
habitat in the permit area that may be affected by the proposed project. Have you done so? YES [ NO [ ]
RESPONSES FROM THE USFWS AND/OR NMFS SHOULD BE FORWARDED TO CORPS.
16. You are required to contact the State Historic Preservation Officer (SHPO) regarding the presence of historic
properties in the permit area which may be affected by the proposed project? Have you done so? YES [ ] NO [K
]
RESPONSE FROM THE SHPO SHOULD BE FORWARDED TO CORPS.
17. Additional information required by DEM:
A. Wetland delineation map showing all wetlands, streams, and lakes on the property.
B. If available, representative photograph of wetlands to be impacted by project. '
C. If delineation was performed by a consultant, include all dam sheets relevant to the placement of the
delineation line.
D. If a stormwater management plan is required for this project, attach copy.
E. What island use of surrounding property? Woodland - Residential
F. If applicable, what is proposed method of sewage disposal?
Owner's Sip

Date
A-08, Acne- 4AW
4elle56
?04 d4:: 16 v I
lit 4
1!A
1n
i
1453
1453/
I ~ tN
,&6c?y/If
t
2
.73 74
l73
L715
Cai?Pll?onJ
N A N T A H A L A
Odra HH a
im
J1.12
0
s,
1AS
110
HK
N A T I
As
W lliti
JAC K SO W c O.
B O A Q NAME 'A h Q I P M i1yE'
1456
S. R.
FROM END OF PAVEbd MT 5-64n TO END 0E PAVEMENT
ADDITION
IMPROVEMENT
TO BE" PAVED' JP POLES TO BE MOVED
T. POLES TO BE MOVE D 0
W
Wl DTH ? 50
0
SCALE -50
ATE 3- 1 - 94

AJ. ?..,b ........,. .. .. . . . . . . . . . . . . . .
' 'Railroad ...:..:.....................:. ...?.._.?.,.•..d?--
..ControI of Access Line.' .............. ?
ti A
:...............
Slope Stake Line.,....
i
•t'• Culvert. '• •••: •• •,• •'•t• •'• •,• • ?• • • • • • • • • • • • ??? ,
Woods .'....:'..•......:...........
Teleplioneor.Telc-rapli Pole ......... i1:?1 i'r -o- 1111101; -_O_
Tower Pole and Line.....::.........,
Tower Pole .:'::.:.......:............, d i tt?it(?t' b i
Easement, Lille..:.::...:..... • • . . • .:.'
?1?Iotivin;;LintiC'.'.?'.:•....:.•....'....... ; . ?--••-+•------'`._,_.`•?,?
Guard Rail ..'...' ......::........:•... T
SanitarySew -----
WaterLine:'.'•.'• •••'..•••••.•••... ---It---
Gas Line .•.....'...• :.':... • .......:..::. ' GAS
1'tcClrUSr:u ExISTIN0
Chain Link Fence•' ..................? -?-?= -o 0-
Woven Wire Fence :.................. -?---?-- --o----o--
RecldneraEiOll
Reforestation ': :..::...................
Temporary Silt Ditch ............ .. 't :57 -- TSU-----
• i
Temporary Silt Fence ................. --fh---=--11i- -I If--
Temporai=y.Slope*Drain' .........:..... :..? i
Brush Barrier .°: O..?..•.. • .:..... • .. • ....•
Silt Check Dam Type A. .:........... n '
Silt Check Dam Type.B.........:.... .
.Silt Basin q?-pe'A' . • .:.:'....:•.......:..' •?.?.
Silt Basin Type B . :..•..'••.'..•.••..•
Pock Silt Check Dam .... .........:.... .,:...?.?.;?? r.
1 1 i' l 11 Berm ..-0 • : . • • ...... --?• •r-•?• .•--t ?--?• --?• --?•
Temp, Stone Ditch Check ........ • .?
ninn,n ` • ?v
e •.

DITCH CHECK
PPX
.5/1- T CHECK DAM
//V - 5 LLL
;LOPE DRA/N
DITCH TS D
'' -- `-' EM BANKME/V
LT FENCE
V10 ST PE AM CROSSING - -
,
Zll ?DLASS ROVING
-t- :-- F G IR
IPI P RA Ff
5+00 00.
18 MP i
i
JAMS FISHER
-5 0=- RT. 1
SYLVA, N.C.
EDDIE PARRIS
3+?Q
140 SPEEDWELL RD -
CULLOWHEE, N.C.
o
RAY CLEVLAND
RT. I
SYLVA, N.C
'PLIED INDUSTRIAL MATERIALS INC
?RKR I DGE I OFFICE CENTER
TTSBURG, PA. 15275 ,
O 5 000 L+00
10 + 00
r
0
c
0
O
10.* 00
1
cr.
it CMP.
?l .
i , ,. .
5 0'--?-
5+00 5100
O
SARAH HINES
WOLF LAUREL RESORT
MARS H ILL, NC.
0
C,
15;00 15+00
3
b
.f--- 5
8
o'
d
9
9
C
fl
i
9
I
Oq
5 0 •-?.
19" CMP
10+00 10 ' 00
20 00 20+00
I
5 0=--?)
0
25.00 25.+00
I
I?
5 0=>?
C,
O
is
20+00
i
p?
O
0
J
0
0

o
?V VV
ie" CM
ROBERT MILLS
RT.
SYLVA, N.C.
0
c
C',
STA. 42+2O= 43.05
REDUCE R/W TO 17' LFT. OF CL
4C
T V VV
DAISY HENSON
2417 WOODLAND
P KE , NESAW, GA. 30144
i

RUBY KNOWLES
RT.
SYLVA, N.C.
II
O
KATHRYN BRYSON
RT.
SYLV/X, N. C.
G
50+00 50+00
a
6( CM
P
P
4 S) + 901
` DANNY MILLS
306 LOG CABIN RD.
t WAYNESVILLE, N.C.
? i 10
i
0
55+00 55+00
o -
TIMOTHY NORMAN
2606 COTTAGE DR. ie' M l
RICHMOND, VA. 23233 P'
12 e
•
D
I$ MP
L2,-+ 00
y
60 CMP
II

O
io
• o
d
n
A
O

EROSION CONTROL
DETAILS AND
SPECIFICATIONS
St s .ri tion ?y
245.03 Temporary Silt Ditch
245.05 Temporary Diversion '
893.01 Temporary Silt Fence
...................... --}}?---tt1--
890.05 Temporary Slope Drain with Earth Berm •- .........
Silt Basin Type A
245.02 Silt Basin Type B
892.04 Temporary Rock Silt Check Type-A
895.10 Temporary Rock Silt Check Type-13
892.01 Temporary Rock Sediment Dam Type-A
. ............
892.02 Temporary Rock Sediment Dam Type-B ...
897.01 Rock Pipe Inlet Protection Type-A
897.02 Rock Pipe Inlet Protection Type-B , _..
894.01 Rock Silt Screen
..............•..............................
245.04 Stilling Basin ...............:.......................... 1= 3
Rock Inlet Protection:
896.01 Type A . ............:.................. A U -- OR •- A
896.02 Type B ............................. .: B M.. OR •• B
896.03 Type C .............................. C Ell. OR -• C
0
12 March, 1992
TEMPORARY SILT FENCE:
r
A temporary silt fence is commonly used at the toe of a fill section to prevent off
site sedimentation. It is made of permeable filter fabric buried at the bottom,
stretched and supported by steel posts. The silt fence reduces the water flow while
retaining the sediment. They may also be used to divert water flow to protected
outlets. Silt fences need to be checked after each significant rainfall to ensure there
effectiveness. They must be maintained on a regular basis. Silt fences shall D= be
installed across streams, ditches, or watearways.
ARE ,s OF USE:
At toe of fill sections where sediment runoff can be stored and contained
inside the project limits.
DESIGN CRrrmA:
Material ?1thOUt WIrE
Fabric Type 3 Class A -Type 3 Class B
Steel posts length; S ft 5 ft.
Post spacing 10 ft.. 6 ft. maximum
r- _

0

wo
a??
?z
? t> w
v
3tE w ?
? daa
w
J
0
m ?co
C
az
F?
?o
O 'a
E is
Er O
O w.
A w
W
da
A.d
ox
E» co

`II d
?z
0404

=
4 1 d E+
w
.
-- ww

1 ----
-------
zo
o Ey
?z
t;
4314
a
a w
ao A
N

_
I I

a"
a --
-
1
w
a . 111
a w c, I I I
o?
d , ,
w
z
F _ o w z

-

0?4 E-

-Mm zw
t La.

\
ow ,
w
1 d?
z Q1=E0-.wOV?

a x
?e.
,x aw zww
aAattiwx
... ,
`ate
d=? d „wzaP
tWddw-Jwrei
oaOM
.
aAa aaW&3E-
,
dd >» ?
dm v

NxZ be .,
OZW..
azima L.d E?
wA3a? Ew.: zcw.wFw
ME-wj- ha
oxwad. ° wz
z -ow Ota.A xd
>i
aja
°z
F!c
LJLJ
U
Z
LLJ
LL
F-
U
? z^
Q
oc: ???z
O x?x
Cl-
0
°z w
ga
HQ
Q
a
Q?
O
F-
O
UT
TEMPORARY ROCK Sn.T CHECK TYPE.-BS
A temporary rock silt check type-B (also called check dam) is a small dam with a
weir used to reduce gullying in drainage ditches that are to be filled or
permanently stabilized at a later date. These type-B rock silt checks help reduce
the flow velocity and are generally made of class-B stone. They are used in ditches
during construction where the grade meets and/or exceeds 3%.
AREAS OF USE:
• In channels, roadside ditch outlets, temporary silt ditches, and temporary
diversions.
• In conjunction with type-B silt basins.
DESIGN CRmRIA:
• Center of rock silt check shall be at least 1 foot lower than the outer edges
(top of channel sides)
• The spacing (ft.) = (3 / % of ditch grade) X 100-ft.

27 March; 1992

x
v
N
0
Z J (X
JQZ
1O .. , 3
?/?
VIO=OZZ w
mcnc.loo w >
ZOW N
m Z
O
Z=oc0
O
JV¢i-
W• i _
CL
OE
4TWOCS -M
0
W• ac-LL• N , J
ZGOCtn1Wocr.
(LWO
m
i

^
W
---
OWN Z(A ' ;
W1-- ¢01-04 :: ,

W Z U.-O.=)* r.
c
a N 1

p
V
=
,
?
° H m..,
w c c O
a
(r w IA. am
> o

¢N
w w Z
O
co co
1-
a
=
o
W
Z
a o
"
00

> wt-
wo w¢
Z

J Oui
ow
NN
°- > % ?
CC
U a
V <1

h-
z a
o'@
Z
m
m
LLJ
CL
Y
v
w
u
H
J zV.
U ==s
O ac c
00
?j
z
Q Qva
CD
w
M
Q
Z
Q
1--
0
A
n
L,
28
March,1992

ROCK SILT SCREEN:
A rock silt screen is a low-level dam structure to be used in streams below culvert
sites. Rock silt screens shall be used to trap sediment transported by running water
and shall be placed in the stream below the construction site within the right-of-
way, or easement boundary. The rock silt screen utilizes class B stone lined with #5
or #57 stone to produce a ripple-effect in the stream to settle the larger sediment
particles transported in the stream from the construction site. The trapped sediment
shall be cleaned out before the device is removed from the stream.
AREAS OF USE:
• In live streams below construction sites where construction occurs in or
adjacent to the stream.
• In live streams below a culvert construction site.
• Where it can be cleaned before it is removed from stream
DESIGN CRITERIA:
• Structural stone - class B- stone
• Sediment control stone # 5 or # 57 stone
• Dam height - 1.5 ft. minimum and 3 ft, maximum ( shall not be higher than
1 ft. above normal flow of stream)
37
March, 1992
f

w

----- --

A 94 J
°E"WZ W «. Z
p ; a?x Axe
CO Z Z E- 0.0
0 -C -C w V) 1- W E- -3
V4 Cs.
°
zto - cd IX
°Omomw
6- a - c
a o M
w,a
maa E=w xWa
a,
rnw?
..sae°--E° z°dz' = awa
'nxU
z
U
w°0
.
awVO?.z °
p
°w w?E xw
X

.amue°
uz .
m
z co
a
AM-4Ecj.OXMo
ggt- aai?? Aawewo° M eX.adx
O
w =
4co.z.4 04
y
Z
C
1UNUE-V tx/y.. -
N.mcu0.U
w
0

w O
SL ? ?= N

pNJ
S

S
N
Oi
Z
LLI
W
cr
w
IZQIJ
O1
?a
U)
?Uz
0 oom
Lr zz<
gi%
O w>
rr
O "
Q
W
O
38
March,1992
2 0

THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE WORKMEN'S COMPENSATION ACT
1. C. NUMBER
NORTH CAROLINA INDUSTRIAL COMMISSION E
MP. CODE NO.
CARRIER CODE NO.
RALEIGH. NORTH CAROLINA CARRIER FILE NO.
ITEMIZED STATEMENT OF CHARGES FOR DRUGS Refer to I. C. File No. in con
pondence about this injury.
EMPLOYEE: R. A. Allison ADDRESS: P.O. BOX 664, Dillsboro, NC
EMPLOYER: North Carolina Dept. of Transportation DATE OF INJURY 6-23-94
UAT?_ DRUG STORE
6/24/94 Eckerd Drug Sylva
6/24/94 Echerd Drug Sylva
PRESCRIPTION
NUMBER PHYSICIAN AAIOt
319399 R. S.Queen $36.29
319398 r. S. Queen $ 4.09
- TOTAL Is 40.38
This is to certify that the drugs listed above were related to my workmen's compensation injury.
(Receipts must be furnished for carrier's file)
REIMBURSE EMPLOYEE
EMPLOYEE SIGNATURE
YES p NO CARRIER'S APPROVAL
?
REIMBURSE DRUG STORE
YES (3 NO E]
MAIL YOUR BILL PROMPTLY TO EMPLOYER
ORIGINAL AND ONE COPY OF THIS REPORT MUST BE MAILED TO THE COMMISSION BY EMPLOYER
OR INSURANCE CARRIER