20240314 Ver 1_printed PCN_20240424

DWR
DIvlsion of VN.Vw Resources
Pre-Construction Notification (PCN) Form
For Nationw de Perm its and Regional G eieral Perm its
(along w ith corresponding Water Q L.ality Certifications)
Decem ber 4, 2023 Ver 4.3
Please note: fields m arked with a red asterisk below are required. You will not be able to subm t the form until all
m andatory questions are answered.
Also, if at any point you wish to print a copy of the E-PCN, all you need to do is right-click on the docum eit and you can
print a copy of the form.
Below is a link to the online help file.
https://edocs.deq.nc.gov/WaterResources/DocView.aspx?dbid=0&id=2196924
A. Processing Inform ation
If this is a courtesy copy, please fill in this with the subm ssion date.
Does this project involve maintenance dredging funded by the Shallow Draft Navigation Channel Dredging and
Aquatic Weed Fund or involve the distribution or transmission of energy or fuel, including natural gas, diesel,
petroleum,or electricity?
Yes No
Is this project connected w th ARPA funding?*
Yes No
County (or Counties) w here the project is located:
Durham

Is this a NCDM S Project
Yes No
Click Yes,only if NCDM S is the applicant or co-applicant.
DO NO TCHECK YES, UNLESS YO UARE DM SO RCO APPLICANT.
Is this project a public transportation project?
Yes No
This is any publicly funded by m inicipal,state or federal funds road,rail,airport transportation project.
1 a. Type(s) of approval sought from the Corps:*
Section 404 Perm t (wetlands, stream sand waters, Clean Water Act)
Section 10 Perm t (navigable waters, tidal waters, Rivers and Harbors Act)
Has this PCN previously been subm fitted?
Yes
No
1 b. What type(s) of perm it(s) do you w ish to seek authorization?
Nationwide Perm t (NWP)
Regional G eneral Perm t (RG F)
Standard (IP)
1c. Has the NWP or G Pnumber been verified by the Corps?*
Yes No
Nationw Ue Permit (NWP) Number: M ultiple NWP#'s (specify below)
NWP Num bers (for m ultiple NWPS):
NWP- 3 and NWP - 13
List all NW num bers you are applying for not on the drop down list.
1 d. Type(s) of approval sought from the DW R:
check all that apply
401 Water Q Lality Certification - Regular 401 Water Q Lality Certification - Express
Non-404 Jurisdictional G aneral Perm t Riparian Buffer Authorization
Individual 401 Water Q uality Certification

le. Is this notification solely for the record because w dtten approval is not required?
For the record only for DW R 401 Certification: Yes No
For the record only for Corps Perm it: Yes No
1f. Is this an after-the-fact perm it application?
Yes No
1 g. Is paym ent into a m itigation bank or in-lieu fee program proposed for m itigation of im pacts?
If so,attach the acceptance letter from m itigation bank or in-lieu fee program.
Yes No
Acceptance Letter Attachment
Click the upload button or drag and drop files here to attach docum art
_ILF-Request-Fillable-Form-Dec2022 m tigation nc deq printed.pdf 315.21 KB
FILE TYPE MUST BE PDF
1 h. Is the project located in any of NC's twenty coastal counties?*
Yes No
1 j. Is the project located in a designated trout w Etershed?
Yes No
Link to trout inform ation: http://www.saw.usace.arm Xm I/M ssions/Regulatory-Perm t-Program/Agency-
Coordination/Trout.aspx
B. Applicant Information
1 a. Who is the Primary Contact?*
John Farrell,AICP, CEP
1 b. Primary Contact Em ail:* 1 c. Primary Contact Phone:*
jfarrell@am iengineering.co (xxx)xxx-xxxx
m [phone]
1 d. Who is applying for the perm it?
O caner Applicant (other than owner)
(Check all that apply)

1 e. Is there an Agent/Consultant for this project?
Yes No
2. Ow per Information
2a. Nam e(s) on recorded deed:*
United States of Am erica
2b. Deed book and page no.:
57/92
2c. Contact Person:
(for Corporations)
Cam eron Thom pson, PE
2d.Address*
Street Address
111 T.W.Alexander Drive
Address Line 2
City State/Province/Region
Research Triangle Park NC
Postal/Zip Code Country
27709 USA
2e. Telephone Number:*
(xxx)xxx-xxxx
[phone]
2f. Fax Number:
(xxx)xxx-xxxx
2g. Email Address:*
cam eron.thom [e-mail]
3. Applicant Information (if different from ow rer)
3a. Name:*
Thomas D'Am co

3b. Business Name:
(if applicable)
CMCBuilding, Inc.
3c.Address*
Street Address
2140 Page Road
Address Line 2
Suite 103
City State/Province/Region
Durham, NC
Postal/Zip Code Country
27703 USA
3d. Telephone Number:*
[phone] 3e. Fax Number:
(xxx)xxx-xxxx (xxx)xxx-xxxx
3f. Em ail Address:*
tdam ico@cm dbuildinginc.com
4. Agent/Consultant (if applicable)
4a. Name:*
John Farrell,AICP, CEP
4b. Business Name:
(if applicable)
4c.Address*
Street Address
100 G ateway Center Parkway
Address Line 2
Suite 200
City State/Province/Region
North Chesterfield VA
Postal/Zip Code Country
23235 USA

4d. Telephone Number:
[phone] 4e. Fax Number:
(xxx)xxx-xxxx (xxx)xxx-xxxx
4f. Email Address:*
jfarrell@am iengineering.com
C. Project Inform ation and Prior Project History
1. Project Information
1 a. Nam a of project:*
Repair NIH Dam Inlets and O Wets - 111 T.W.Alexander Dr.
1 b. Subdivision name:
(if appropriate)
1 c. Nearest municipality/town*
Durham
2. Project Identification
2a. Property Identification Number: 2 b. Property size:
(tax PIN or parcel ID) (in acres)
0737664416 504.2
2c. Project Address
Street Address
109 T.W.Alexander Dr.
Address Line 2
City State/Province/Region
Durham NC
Postal/Zip Code Country
27703 USA
2d. Site coordinates in decimal degrees
Please collect site coordinates in decim al degrees. Use between 4-6 digits (unless you are using a survey-grade G FS
device) after the decim al place as appropriate, based on how the location was determ ned. (For exam Oe, m cst m cbile
phones with G F5 provide locational precision in decim d degrees to m ap coordinates to 5 or 6 digits after the decim al

place.)
Latitude:* Longitude:
35.885770 -78.875997
ex:34.208504 -77.796371
3. Surface Waters
3a. Nam a of the nearest body of water to proposed project:
Discovery Lake
3b. Water Resources Classification of nearest receiving w ater:
Burden's Creek
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Cape Fear
3d. Please provide the 12-digit HUC in w tich the project is located.
030202011001
River Basin Lookup
4. Project Description and History
4a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the
time of this application:*
The existing conditions at the NIH/EPA cam pus (site) are an institutional cam pus. The developed facilities are
accessed through paved interior roads and parking. the central feature of the site is Discovery Lake. The lake
is fringed with wetlands and a paved walking path. The existing vegetation is generally m ked hardwoods and
pines. Turf and em argent wetland vegetation com prise m cst of the veg. com m unity adjacent to the lake.
4b. Have Corps perm its or DWR certifications been obtained for this project (including all prior phases) in the
past?*
Yes No Unknown
4f. List the total estimated acreage of all existing w etlands on the property:
10

4g. List the total estimated linear feet of all existing streams on the property:
(interm[tent and perennial)
5,000
4h. Explain the purpose of the proposed project:
The project purpose is to rehabilitate the Lake Discovery Dam to current safety standards and to provide
shoreline protection in the form of rip rap, stone walls and vegetation.
4i. Describe the overall project in detail, including indirect impacts and the type of equipment to be used:
installation of the slip line repair pipes. Construct a tem porary cofferdam,approx. 150 ft long x 20 ft wide x 4 ft
tall, using earth materials obtained from below norm el pool to ensure the work area is dry. Upon com pletion of
the slip line repair, the cofferdam earthen materials will be redistributed back to the area below normal pool.
Addition of rip rap stone for wave arm cr on the upstream dam slope.
Lake Aeration -Tern porary use of an aeration system with approx. 1200 linear feet of aeration tubing leading
to 10 aeration diffusers to ensure waters drained from the bottom of the lake are not oxygen deprived and
species in the outfall stream are not harm ed.
Shoreline Stabilization - Installation of vegetative, rip rap, and stone retaining wall sections to stabilize eroded
sections around the lake perim eter.Approx. 500 I.f vegetative, 750 I.f rip rap, and 1000 I.f. stone wall.
Lake Aeration - are proposed to be tem porarily placed within the lake. The tubes will be pressurized via a
m anifold on the northwestern portion of the shoreline. The tubes will disperse atm cspheric air into the lake
bottom to im prove low oxygen levels in the water prior to it being drained from the lake.Aeration activities are
estim aced to begin in M arch 2024 and anticipated to proceed for approx. 1 m cnth.
Dam and Spillway-The proposed slip line repair is a non-invasive m ethod to restore the principal spillway
and bottom drain conduits to perm anent service. Pipe repair activities are estim aced to begin in April 2024 and
will proceed for approx. 2 m cnths. The wave protection arm cr on the upstream face of the dam is required by
NC DEQ for High Hazard dam sand will be constructed of riprap beginning approx. M ay 2024 and proceed for
approx. 1 m cnth.
Shoreline Stabilization - Portions of the shoreline of Discovery Lake are eroding and sloughing into the lake.
Wetland vegetation, rip rap and stone walls are proposed to alleviate erosion along the shoreline. Heavy
equipm ent and hand tools are proposed for this work.
For the fish rem o✓al, the plan is as follows:
1. Lower lake level several feet
2. Shock fish to get a sampling (this will help determ he the am cunt of Rotenone to use)
3. Keep lake level down several feet, close valve, apply Rotenone one evening to kill all fish (the lowered pool
will keep Rotenone from escaping downstream)
4. The next m crning, use boats to collect fish and haul off site in trucks.
5.Allow several days duration for Rotenone to dissipate, test for when levels are safe to release water.
6. Drain lake entirely.
5. Jurisdictional Determinations
5a. Have the w etlands or streams been delineated on the property or proposed im pact areas?
Yes No Unknown

Com m eits:
5b. If the Corps m ade a jurisdictional determ ination, w hat type of determ ination w as m ade?
Prelim nary Approved Not Verified Unknown N/A
Corps AID Number:
Exam die: SAW-2017-99999
SAW-2023-01325
5c. If 5a is yes, who delineated the jurisdictional areas?
Name(if know ri: John J. Farrell
Agency/Consultant A. M crton Thom as and Associates
Com pany:
O her:
5d. List the dates of the Corp jurisdiction determ ination or State determ ination if a determ ination w a; m ade by
the Corps or DWR.
09/27/2023 - USACE
6. Future Project Plans
6a. Is this a phased project?*
Yes No
Are any other NWP(s), regional general perm it(s), or individual perm its(s) used, or intended to be used, to
authorize any part of the proposed project or related activity? This includes other separate and distant
crossing for linear projects that require Department of the Army authorization but don't require pre-
construction notification.
No
D. Proposed Impacts Inventory
1 . Impacts Sum may

1a. Where are the impacts associated w th your project? (check all that apply):
Wetlands Stream atributaries Buffers
O pen Waters Pond Construction
2. Wetland Impacts
If there are w bland im pacts proposed on the site, then complete this question for each w etland
area impacted.
"W." w it be used in the table below to represent the w crd "w etland".
2a. Site 2a1 Reason* 2b. Impact 2c. Type of W.* 2d. W.nam e* 2e. 2f. Type of 2g.
#*('> (?) type* M Forested Jurisdicition* Im pact
M area
1 d am work P N on-Tidal LEM #1A I o B oth 0.091
Freshwater M arsh (acres)
2 d am work P N on-Tidal LEM/LSS o B oth 0.006
Freshwater M ash #1A (acres)
3 s horeline P N on-Tidal LEM/LSS o B oth 0.023
restore Freshwater M arsh #1 B (acres)
4 s horeline T N on-Tidal LEM/LSS o B oth 0.022
restore Freshwater M arsh #2A (acres)
5 s horeline P N on-Tidal LEM/LSS o B oth 0.048
restore Freshwater M arsh #3A (acres)
6 a ccess T III on-Tidal LEM/LSS o B oth 0.005
Freshwater M ash #313 (acres)
7 s horeline T N on-Tidal LEM/LSS o B oth 0.038
restore Freshwater M arsh #3C (acres)
8 s horeline P N on-Tidal LEM/LSS o B oth 0.025
restore Freshwater M arsh #3D (acres)
9 s horeline T N on-Tidal LEM/LSS o B oth 0.052
restore Freshwater M ash #3E (acres)
10 a ccess T III on-Tidal LEM/LSS o B oth 0 .002
Freshwater M ash #3F (acres)

11 s horeline T N on-Tidal LEM/LSS o B oth 0 .009
restore Freshwater M ash #3G (acres)
12 a ccess T III on-Tidal LEM/LSS o B oth 0.006
Freshwater M ash #3H (acres)
13 s horeline P N on-Tidal LEM/LSS o B oth 0.034
restore Freshwater M ash #4A (acres)
14 s horeline P N on-Tidal LEM/LSS o B oth 0.051
restore Freshwater M ash #4B (acres)
15 s horeline P N on-Tidal LEM/LSS o B oth 0.003
restore Freshwater M ash #4C (acres)
16 s horeline P N on-Tidal LEM/LSS o B oth 0.035
restore Freshwater M ash #5A (acres)
17 s horeline P N on-Tidal LEM/LSS o B oth 0.010
restore Freshwater M ash #5B (acres)
18 s horeline T N on-Tidal LEM/LSS o B oth 0.020
restore Freshwater M ash #5C (acres)
19 s horeline P N on-Tidal LEM/LSS o B oth 0.027
restore Freshwater M ash #5D (acres)
20 b ridge repair P N on-Tidal LEM/LSS o B oth 0.002
Freshwater M ash #6A (acres)
21 s horeline T N on-Tidal LEM #3A o B oth 0.001
restore Freshwater M ash (acres)
22 s horeline P N on-Tidal LEM #3B o B oth 0.027
restore Freshwater M ash (acres)
23 s horeline P N on-Tidal LEM #3C o B oth 0.038
restore Freshwater M ash (acres)
24 s horeline P N on-Tidal LEM #3D o B oth 0.027
restore Freshwater M ash (acres)
25 s horeline T N on-Tidal LEM/LSS o B oth 0.046
restore Freshwater M ash #7A (acres)

2g. Total Temporary Wetland Impact
0.201
2g. Total Permanent Wetland Impact
0.447
2g. Total Wetland Impact
0.648
2i. Comments:
4. O pen Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic O man,
or any other open w ater of the U.S. then individually list all open w ater im pacts below .
4a. Site 4a1. Impact 4b. Impact 4c. Nam a of w aterbody 4d. Activity 4e. Waterbody 4f.
##* (?) Reason type* (?) (?) type* type* Im pact
area
26 c offer dam P TEMP iscovery Lake S tabilization L ake 0.12
(acres)
27 r etaining wall iscovery Lake S tabilization L ake 0.047
(acres)
28 r ip rap on TEMP iscovery Lake S tabilization L ake 0.12
shore (acres)
29 r ip rap dam P TEMP iscovery Lake S tabilization L ake 0.13
(acres)
30 a it diffusers T TEMP iscovery Lake O her L ake 0.14
(acres)
4g. Total temporary open water Impacts:
0.51
4g. Total permanent open water impacts:
0.047

4g. Total open w ater impacts:
0.0557
4h. Comments: Open water impacts have been revised to comply with NWP #3 and NWP #13. Geotextile
fabric is to be used on the face of the dam only. Rip rap is to be placed on the surface of existing ground.
No fill material or excavation is allowed. No retaining wall face is to extend from the normal edge of water
more than 4' into Discovery Lake. TOTAL PERMANENT IMPACT TO WoUS - 0.494 ACRES
6. Buffer Im pacts (for DWR)
If project w it impact a protected riparian buffer, then complete the chart below .Individually list
all buffer impacts below .
6a. Project is in w tich protect basin(s)?
Check all that apply.
Neuse Tar-Pam lco
Catawba Randlem an
G aose Creek Jordan Lake
O her
...........................
6b. Im pact Type*M 6c. Per or 6d. Stream name* 6e. Buffer m itigation 6f. Zone 1 6g. Zone 2
Tern p*M I required?* im pact* im pact*
allowable P B urden's Creek N o 0 0
(square feet) (square feet)
6h. Total buffer impacts:
Zone 1 Z one 2
Total Temporary impacts: 0.00 0 .00
Zone 1 Z one 2
Total Permanent impacts: 0.00 0 .00
Zone 1 Z one 2

Total combined buffer 0.00 0 .00
im pacts:
6i. Comments:
All buffer im pacts are allowable and are exem pt from m tigation.All proposed work is for
shoreline stabilization and for dam safety/m antenance. No new im pervious areas are
planned.
E. Impact Justification and M kigation
1 . Avoidance and M nim cation
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:
lim ting cut and fill areas to the absolute m him u-n.
1 b. Specifically describe m easures taken to avoid or m inim¢e the proposed im pacts through construction
techniques:*
lim t access areas through wetlands to the sm allest footprint possible.
2. Compensatory M itigation for Impacts to Waters of the U.S. or Waters of the
State
2a. Does the project require Compensatory M tigation for impacts to Waters of the U.S. or Waters of the State?
Yes No
2c. If yes, m itigation is required by (check all that apply):
DW R Corps
2d. If yes, w Hch m itigation option(s) w it be used for this project?
M tigation bank Paym ent to in-lieu fee program Perm ttee Responsible M tigation
4. Complete if Making a Payment to In-lieu Fee Program
4a.Approval letter from in-lieu fee program is attached.
Yes No

4b. Stream mitigation requested: 4c. If using stream m itigation, w hat is the stream
(linear feet) tem perature:
0
NC Stream Tern perature Classification M aps can be found under the M tigation Concepts tab on the Wilm hgton
District's RIBITS website.
4d. Buffer m itigation requested (DWR only): 4 e. Riparian w etland m itigation requested:
(square feet) (acres)
0 0
4f. Non-riparian w etland m itigation requested: 4 g. Coastal (tidal) w etland m itigation requested:
(acres) (acres)
0 0
4h. Comments
All work within the buffer is to m eet dam safety regulations and to relieve shoreline
erosion. This is a buffer exem pt project.
6. Buffer m itigation (State Regulated Riparian Buffer Rules) - required
by DWR
6a. Will the project result in an im pact w thin a protected riparian buffer that requires buffer m itigation? If yes,
you m ust fill out this entire form - please contact DWR for more information.
Yes No
F. Stormwater Management and Diffuse Flow Plan (required
by DWR)
." Recent changes to the storm\Rater rules have required updates to this section .***
1 . Diffuse Flow Plan
1a. Does the project include or is it adjacent to protected riparian buffers identified w thin one of the NC
Riparian Buffer Protection Rules?
Yes No
1b.All buffer impacts and high ground impacts require diffuse flow or other form of stormweter treatment. If
the project is subject to a state implemented riparian buffer protection program,include a plan that fully
documents how diffuse flow w 11 be maintained.

All Storm water Control Measures (SCM)s must be designed in accordance w th the NC Storm water Design
M anual. Associated supplement forms and other documentation shall be provided.
What type of SCM are you providing?
Level Spreader
Vegetated Conveyance (lower SHWT)
Wetland Swale (higher SHWT)
O fier SCM that rem aces m him urn 30% nitrogen
Proposed project will not create concentrated storm voter flow through the buffer
(check all that apply)
For a list of options to meet the diffuse flow requirements, click here.
2. Storm water M anagem ent Plan
2a. Is this a NCDO Tproject subject to compliance w th NCDO Ts Individual NPDES perm it NCS000250?
Yes No
Com m ents:
dam safety upgrades and shore stabilization only. No swm plan required.
G .Supplementary Information
1 . Environmental Documentation
1a. Does the project involve an expenditure of public (federal/state/local) funds or the use of public
(federal/state) land?*
Yes No
1b. If you answ Bred "yes" to the above, does the project require preparation of an environmental document
pursuant to the requirements of the National or State (North Carolina) Environmental Policy Act (NEPA/SEPA)?
*
Yes No
1c. If you answered "yes" to the above, has the document review been finalized by the State Clearing House?
(If so, attach a copy of the NEPA or SEPA final approval letter.)*
Yes No

Com m eits:*
NEPA is required but is not prepared.
2. Violations (DWR Requirement)
2a. Is the site in violation of DWR Water Q uality Certification Rules (15A NCAC 2H .0500), Isolated Wetland
Rules (15A NCAC 2H .1300), or DWR Surface Water or Wetland Standards or Riparian Buffer Rules (15A NCAC
2B .0200)?*
Yes No
3. Cum ulative I pacts (DWR Requirem ent)
3a. Will this project (based on past and reasonably anticipated future impacts) result in additional
development, which could impact nearby dow rstream water quality?*
Yes No
3b. If you answered "no," provide a short narrative description.
4. Sew age Disposal (DWR Requirement)
4a. Is sew age disposal required by DWR for this project?
Yes No N/A
5. Endangered Species and Designated Critical Habitat (Corps
Requirement)
5a. Will this project occur in or near an area w th federally protected species or habitat?*
Yes No
5b. Have you checked w th the USFWS concerning Endangered Species Act impacts?*
Yes No
5d. Is another Federal agency involved?*
Yes No Unknown
What Federal Agency is involved?
NIH

5e. Is this a DO Tproject located w thin Division's 1-8?
Yes No
5f. Will you cut any trees in order to conduct the w o-k in w aters of the U.S.?
Yes No
5g. Does this project involve bridge m aintenance or removal?*
Yes No
Link to the NLEB SLO FES document: http://saw-reg.usace.army.m i/NLEB/1-30-17-signed_NLEB-SLO FES&apps.pdf
5h. Does this project involve the construction/installation of a w hd turbine(s)?*
Yes No
5i. Does this project involve (1) blasting, and/or(2) other percussive activities that w it be conducted by
machines, such as jackhammers, mechanized pile drivers, etc.?*
Yes No
5j. What data sources did you use to determine w hether your site w culd impact Endangered Species or
Designated Critical Habitat?*
USFWS IPaC
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?
Yes No
6b. What data sources did you use to determ ine w[ether your site w culd im pact an Essential Fish Habitat?
USFWS IPaC
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
Link to the State Historic Preservation O fice Historic Properties M ap (does not include archaeological data:
http_//gis.ncdcr.gov/hpoweb/
7a. Will this project occur in or near an area that the state, federal or tribal governments have designated as
having historic or cultural preservation status (e.g., National Historic Trust designation or properties
significant in North Carolina history and archaeology)?*
Yes No

7b. What data sources did you use to determine w[ether your site w culd im pact historic or archeological
resources?*
All work is to be performed along the lake shoreline and on the Discovery Lake Dam
within a closed federal gov. cam pus.
8. Flood Zone Designation (Corps Requirement)
Link to the FEMA Floodplain M aps: https:Hm sc.fem agov/portal/search
8a. Will this project occur in a FEM Ardesignated 100-year floodplain?
Yes No
8b. If yes, explain how project meets FEM Arequirem ents:
8c. What source(s) did you use to m ake the floodplain determ ination?
FEM AFIRM ette
M iscellaneous
Com m eits
Please use the space below to attach all required documentation or any additional information you feel is
helpful for application review.Docum ents should be com tined into one file w hen possible, w th a Cover Letter,
Table of Contents, and a Cover Sheet for each Section preferred.
Click the upload button or drag and drop files here to attach docum art
Discovery Lake JDR- NIH - Durham NC.pdf 6 .38M B
Discovery Lake Perm t Set 9-26-23.pdf 1 0.93M B
File m ust be PDF or KM Z
Signature
*
By checking the box and signing below, I certify that:

• The project proponent hereby certifies that all information contained herein is true, accurate, and compete
to the best of my knowledge and belief'; and
• The project proponent hereby requests that the certifying authority review and take action on this CWA401
certification request within the applicable reasonable period of time.
• 1 have given true, accurate, and com Pete information on this form;
• 1 agree that subm ssion of this PCN form is a "transaction" subject to Chapter 66, Article 40 of the NC
G eneral Statutes (the "Uniform Electronic Transactions Act");
1 agree to conduct this transaction by electronic m eans pursuant to Chapter 66, Article 40 of the NC
G eneral Statutes (the "Uniform Electronic Transactions Act");
• 1 understand that an electronic signature has the sam a legal effect and can be enforced in the sam eway as
a written signature;AND
• 1 intend to electronically sign and subm t the PCN form.
Full Name:*
John J. Farrell
Signature*
Date
2/20/2024