20220928 Ver 1_401 Application_20220712

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NORTH CARO.INA
Staff Review Form
Envlmnm¢ntrtl Qvofiry
Updated September2020
Staff Review
Does this application have all the attachments needed to accept it into the review process?*
Yes No
ID#* Version* 1
20220928
Is this project a public transportation project?* Yes
No
Is this a DOT Yes No
project?*
Reviewer List:* Rob Rid ings:eads\rgridings
Select Reviewing Office:* Central Office-[phone]
Does this project require a request for payment to be sent?*
Yes
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:* For the Record Only(Courtesy Copy)
New Project
Modification/New Project with Existing ID
More Information Response
Other Agency Comments
Pre-Application Submittal
Re-Issuance\Renewal Request
Stream or Buffer Appeal
Pre-Filing Meeting Date Request was submitted on:
Project Contact Information
...............................................................................................................................................................................................................
Name: NCDOT Div 5
Who is submitting the information?
Email Address: [e-mail]
Project Information
........................................ ................................
Project Name: Campbell Road
Is this a public transportation project?
Yes
No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
Yes No Unknown
TIP#: WBS#:
(Applies to DOT projects only)
..................................................................................................
County(ies)
Wake
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach document
NCDOT DIV 5 non-reporting NWP_2022 January-
412.49KB
June_-D I V05-330919L.pdf
Only pdf or kmz files are accepted.
Describe the attachments or
comments:
Jan-June 2022 Non-reporting
Sign and Submit
..................................................................................
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 automatically.