20210862 Ver 1_401 Application_20210423

Staff Review Form •
NORFH CA.,i0:INA
En vironmenfrr!QvoGry
Updated September 4,2020
Staff Review
Does this application have all the attachments needed to accept it into the review process?*
6* Yes r No
ID#* Version* 1
20210862
Is this project a public transportation project?* (' Yes
r No
Is this a DOT ( Yes C No
project?*
Reviewer List:* Garcy Ward:eads\gpward
Select Reviewing Office:* Washington Regional Office-[phone]
Does this project require a request for payment to be sent?*
Yes
r
No

Project Submittal Form
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 Type:* r For the Record Only(Courtesy Copy)
r New Project
r Modification/New Project with Existing ID
✓ More Information Response
✓ Other Agency Comments
r Pre-Application Submittal
✓ Re-Issuance\Renewal Request
✓ Stream or Buffer Appeal
Project Contact Information
Name: Steve Trowel)
Who is submitting the inforrration?
Email Address: [e-mail]
Project Information
Project Name: Pipe Replacement SR 1122 Broadneck Road Bertie Co.
Is this a public transportation project?
r Yes
✓ No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
✓ Yes r No r Unknown
TIP#: WBS#:
1 B.200811
(Applies to DOT projects only)
County(ies)
Bertie
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach document
Topo SR 1122 Broad Neck Road Pipe Replacement
1.25MB
Bertie County.pdf
RE_Moratorium Relief for Pipe Replacement on SR
174.59KB
1122 Broad Neck Road Bertie County.pdf
Only pdf or krre files are accepted.
Describe the attachments
or comments:
This is a courtesy notification that NCDOT will be replacing a pipe in a jurisdictional area in Bertie County
under Nationwide Permit 3 conditions. location is on Coniott creek, Stream Index 23-48,water classification C
in the Roanoke River Basin.
Existing (3)46'x 60"CMP to be replaced with (3)50'x 66"CAP at N 36.001169°,W-77.12238°

Sign and Submit
fJ By checking the box and signing box below, I certify that:
• I,the project proponent, hereby certifies that all information contained herein is true,accurate, and complete to
the best of my knowledge and belief.
• I,the project proponent, hereby requests that the certifying authority review and take action on this CWA 401
certification request within the applicable reasonable period of time.
• I agree that submission of this online 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 online form.
Signature:
Submittal Date: Is filled in autocratically.