20201248 Ver 1_401 Application_20210113

DWR
mrlslon of Water Resources
Pre -Construction Notification (PCN) Form
April 11, 2020 Ver 3.1
Initial Review
Has this project met the requirements for acceptance in to the review process?*
r Yes
r No
Is this project a public transportation project?*
C Yes r No
Change only if needed.
BIMS # Assigned
20201248
Is a payment required for this project?*
r No payment required
r Fee received
r Fee needed - send electronic notification
Reviewing Office *
Raleigh Regional Office - [phone]
Information for Initial Review
1a. Name of project:
The Glen/The Meadows at Hollybrook
1a. Who is the Primary Contact?*
Deborah Shirley
1b. Primary Contact Email:*
[e-mail]
Date Submitted
1/13/2021
Nearest Body of Water
Buffalo Creek (Wendell Lake)
Basin
Neuse
Water Classification
QNSW
Site Coordinates
Latitude: Longitude:
35.766216-78.363371
A. Processing Information
County (or Counties) where the project is located:
Wake
Johnston
Is this a NCDMS Project
r Yes r No
Is this project a public transportation project?*
r Yes r No
1a. Type(s) of approval sought from the Corps:
* Section 404 Permit (wetlands, streams and waters, Clean Water Act)
r Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
Version#*
1
What amout is owed?*
r $240.00
r $570.00
Select Project Reviewer*
Stephanie Goss:eads\szgoss
1c. Primary Contact Phone:*
[phone]
L.1
1b. What type(s) of permit(s) do you wish to seek authorization?

W Nationwide Permit (NWP)
r Regional General Permit (RGP)
r Standard (IP)
1c. Has the NWP or GP number been verified by the Corps?
r Yes r No
Nationwide Permit (NWP) Number:
NWP Numbers (for multiple NWPS):
NWP 12 for offsite utility
1d. Type(s) of approval sought from the DWR:
W 401 Water Quality Certification - Regular
r Non-404 Jurisdictional General Permit
r Individual Permit
29 - Residential Developments
le. Is this notification solely for the record because written approval is not required?
For the record only for DWR401 Certification:
For the record only for Corps Permit:
r 401 Water Quality Certification - E)iress
V Riparian Buffer Authorization
1f. Is this an after -the -fact permit application?*
r Yes r No
1g. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
r Yes r No
1g. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
r Yes r No
Acceptance Letter Attachment
1h. Is the project located in any of NC's twenty coastal counties?
r Yes r No
1j. Is the project located in a designated trout watershed?
0 Yes r No
B. Applicant Information
1d. Who is applying for the permit?
W Owner r Applicant (other than owner)
le. Is there an Agent/Consultant for this project?*
r Yes r No
2. Owner Information
2a. Name(s) on recorded deed:
Smith Edwards LLC
2b. Deed book and page no.:
DB: 012538, 018106, 013847, 03816 DP: 01623, 02401, 01368, 0621
2c. Responsible party:
Fred J. Smith Jr.
2d.Address
Street Address
2505 Wendell Road
Address Line 2
City
Wendell
Rbstal / Zip Code
27591
2e. Telephone Number:
[phone]
2g. Email Address:*
[e-mail]
State / Province / Region
North Carolina
Country
United States
2f. Fax Number:
r Yes r No
r Yes r No
4. Agent/Consultant (if applicable)

4a. Name:
Deborah Shirley
4b. Business Name:
Soil & Environmental Consultants, PA
4c.Address
Street Address
8412 Falls of Neuse Rd., Ste. 104
Address tine 2
City
Raleigh
Fbstal / Zip Code
27615
4d. Telephone Number:
[phone]
4f. Email Address:*
[e-mail]
Agent Authorization Letter*
Agent Authorization Form.pdf
C. Project Information and Prior Project History
1. Project Information
1b. Subdivision name:
(d appropriate)
1c. Nearest municipality/ town:
Wendell
F-
2. Project Identification
2a. Property Identification Number:
1793034587,1783923310,1793151012,
1783949191,& 178300-91-1162
2c. Project Address
Street Address
S Hollybrook Road
Address tine 2
city
Wendell
Postal / Zip Code
27591
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
Buffalo Creek (Wendell Lake)
3b. Water Resources Classification of nearest receiving water:*
C; NS W
3c. What river basin(s) is your project located in?*
Neuse
3d. Please provide the 12-digit HUC in which the project is located.
030202011502
4. Project Description and History
State / Province / IRLgion
NC
Country
United States
4e. Fax Number:
612.46KB
2b. Property size:
+/-71.06 plus +/-28,94 acres for offsite
easement
State / Province / I?gion
NC
Country
United States
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:*
Existing conditions on the property consist primarily of agricultural fields and wooded areas. Some residential structures, adjacent to S Hollybrook Rd, as well as dirt roads are on the
property. There are a total of three (3) perennial streams (SA, SB, & SD), two (2) intermittent stream features (SE & SE2), one (1) linear wetland feature (LW1), thirteen (13) wetland
features (W1-W13), and one (1) pond (Pond 1) on the property. Please see Overall Impact maps for specific locations of each feature on the property. South Hollybrook Road bisects
the properties North and South. The land use in the vicinity of the project is mostly rural development with agricultural and wooded land. There is some residential developments to the
Northwest of the property.
4b. Have Corps permits or DWR certifications been obtained for this project (including all prior phases) in the past?*
F Yes G No F Unknown

4d. Attach an 8 1/2 X 11 excerpt from the most recent version of the USGS topographic map indicating the location of the project site. (for DWR)
USGS with Offsite.pdf
739.31 KB
4e. Attach an 8 1/2 X 11 excerpt from the most recent version of the published County NRCS Soil Survey map depicting the project site. (for DWR)
SS with offsite.pdf 433.41 KB
4f. List the total estimated acreage of all existing wetlands on the property:
Approximately 10.45 acres
4g. List the total estimated linear feet of all existing streams on the property:
Approximately 1,375 LF
4h. Explain the purpose of the proposed project:*
The purpose of this project is for single family residential development and its necessary infrastructure.
4i. Describe the overall project in detail, including indirect impacts and the type of equipment to be used:*
The overall project consists of a single-family residential development and the construction of roadway infrastructure, utilities, pedestrian trail, single-family lots and Stormwater Control
Measures (SCM). Specifically, there are three (3) utility crossings (one offsite) that impact streams, wetlands, and riparian buffers, two (2) road crossings that impact streams, wetlands,
and riparian buffers, one (1) lot fill area that impact wetlands, and one (1) area for pedestrian trail that impacts wetlands. Equipment typically used for construction and earthwork such
as backhoes, bulldozers, excavators, graders, pavers etc. will be utilized for this project.
4j. Please upload project drawings for the proposed project.
The Glen - Existing Conditions Plan.pdf 545.23KB
The Meadows - Existing Conditions Plan.pdf 560.92KB
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or proposed impact areas?*
r Yes r No C Unknown
Comments:
5b. If the Corps made a jurisdictional determination, what type of determination was made?*
r Preliminary r Approved r Not Verified r Unknown r N/A
Corps AID Number:
SAW-2018-02193
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known): Steven Ball
Agency/Consultant Company: Soils & Environmental Consultants, PA
Other:
5d. List the dates of the Corp jurisdiction determination or State determination if a determination was made bythe Corps or DWR
USACE site visit and field verification was completed by Tasha Alexander on January 15, 2019 as well as an updated site visit and field verification with Samantha Dailey on October 14,
2020. Written concurrence was received by Samantha Dailey of the USACE on October 30, 2020; Riparian buffer determination was completed by Gary Kreiser of NCDWR on August
28, 2018.
5d1. Jurisdictional determination upload
Hollybrook Road Sewer - Hollybrook Road Sewer DWR letter.pdf 1.06MB
Hollybrook Road Buffer Determination Letter.pdf 339.64KB
6. Future Project Plans
6a. Is this a phased project?*
r Yes C No
7b. If yes, explain.
The overall project consists of 5 phases, with the first phase split into an "A" ("The Glen") and "B" (The Meadows") to provide units on each side of Hollybrook Road. See attached
phasing plan.
Are any other NWP(s), regional general permit(s), or individual permits(s) used, or intended to be used, to authorize any part of the proposed project or related activity?
It is our understanding that there are no intended future phases beyond the property boundaries shown. Therefore, no additional NWP, Regional General Permits, or IP are anticipated.
D. Proposed Impacts Inventory u
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
* Wetlands W Streams -tributaries fJ Buffers
r Open Waters r Pond Construction
2. Wetland Impacts

2a1 Reason (?)
2b. Impact type * (?)
2c. Type of W.*
2d. W. name *
2e. Forested *
2C Type of
Jurisdicition*(?)
2g. Impact
area"
Impact 2
Lot Fill
P
Headwater Forest
W10
��Both
0.118
(acres)
Impact 3
Road Crossing -Fill
P
Headwater Forest
W12
Both
0.039
(acres)
Im act 3 P
Road CrossingT
Headwater Forest
W12
No
Both
0.008
(Construction Access)
(acres)
Im act 4
P
Pedestrian Trail-
P
Headwater Forest
13
f
Yes
Both
0.001
Grading
(acres)
Impact 5
Road Crossing -Fill
P
Bottomland Hardwood Forest
W2
Yes
Both
0.219
(acres)
Im act 5
P
Road Crossing
9
T
Bottomland Hardwood Forest
W2
Yes
Both
0.009
(Construction Access)
(acres)
Impact 7
Utility Crossing
P
Bottomland Hardwood Forest
W9
Yes
Both
0.005
(Permanent -No
(acres)
Permanent Loss)
2g. Total Temporary Wetland Impact
0.017
2g. Total Wetland Impact
0.399
2h. Comments:
2g. Total Permanent Wetland Impact
0.382
Total permanent loss wetland = 0.377 acres; Total permanent -no permanent loss wetland = 0.005 acres; Total temporary stream = 0.017 acres;
Temporary wetland impacts will be brought back to pre -construction contours and the eAsting adjacent wetland source will assist in the restoration of
the wetland vegetation. Compensatory mitigation is proposed for the permanent loss impacts (culverts) and the Permanent -No Permanent Loss
impacts, the impacts quantified within the permanent maintenance corridor for utilities.
3. Stream Impacts
F13a.
Reason for impact (?)
3b.lmpact type *
3c. Type of impact*
3d. S. name *
3e. Stream Type *
3f. Type of
3g. S. width *
3h. Impact
11 (?)
Jurisdiction"
length"
S1
Impact 1-Utility Crossing
Temporary
Other
Stream
Perennial
Both
8Average
1(li
(fee)
�rfeet)
3Y
Impact 5-Road Crossing
Permanent
Culvert
Stream B
Perennial
Both
1Average(fee)
12nea
feet)
S3
Impact 5-Road Crossing
Temporary
Dewatering
Stream B
Perennial
Both
3
50
(Construction
Average (feet)
(linear feet)
Access/dewatering)
Sq
Impact 5-Road Crossing-
Permanent
Other
Stream B
Perennial
Both
12
20
Dissipater (Permanent -no
Average (feet)
(linearfeet)
permanent loss)
S5
Impact 8-Utility Crossing
emporary
Temporary::]
Other Jream
B
Perennial
Both
9
45
Average (feet)
(lirieerfeet)
31. Total jurisdictional ditch impact in square feet:
31. Total permanent stream impacts:
145
31. Total stream and ditch impacts:
255
3j. Comments:
3i. Total temporary stream impacts:
110
Total permanent loss stream = 125 LF; Total permanent -no permanent loss stream = 20 LF; Total temporary stream = 110 LF; Temporary stream
impacts will be brought back to pre -construction stream bed elevations and the stream banks will be stabilized. Permanent -No permanent loss stream
impacts are locations where riprap will be placed belowthe stream bed to control velocities, the top elevation of the riprap post construction will not
exceed the pre -construction elevation of the stream bed.
6. Buffer Impacts (for DWR)
6a. Project is in which protect basirl
Check all that apply.
F7 Neuse r Tar -Pamlico
r Catawba r Randleman
r Goose Creek F Jordan Lake
r Other

6b. Impact Type 6c. Per or Temp 6d. Stream name 6e. Buffer mitigation required? 6f. Zone 1 impact 6g. Zone 2 impact
Impact 1-Utility Crossing
P
Stream N
No
675
425
Impact 5-Road Crossing
P
Stream B
No
9,000
4,700
Impact 6-Utility Crossing
P
Stream B
No
2,250
1,400
6h. Total buffer impacts:
Zone 1
Total Temporary impacts: 0.00
Zone 1
Total Permanent impacts: 11,925.00
Zone 1
Total combined buffer impacts: 11,925.00
6i. Comments:
Supporting Documentation
lollybrook Impact Maps - 201210.pdf
E. Impact Justification and Mitigation
1. Avoidance and Minimization
Zane 2
0.00
Zane 2
6,525.00
Zone 2
6,525.00
6.06MB
la. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:
S&EC completed a wetland delineation and Neuse River Buffer evaluation for the entire property in order to identify natural resources so that impacts
could be avoided & minimized to the mapmum eMent practicable. Impact 1 is a proposed offsite Force Main utility crossing with temporary stream and
riparian buffer impacts. The utility crossing will be installed utilizing the Bore and Jack construction method to minimize stream impacts. This Force
Main connection is necessary to connect an eAsting line to a new pump station that is located at the southern end of the property south of Hollybrook
Road. Impact 2 is proposed lot fill with permanent wetland impacts. The wetland that is proposed to be filled in this area is considered "loW' quality per
NCWAM. This impact is necessary because NCDOT required road Widening along Hollybrook Road and the fill slopes reduced the developable area
between toe of slope and the eAsting wetland feature W10. These fill slopes are located at the back of the lots that push the houses forward (south)
resulting in the necessary wetland fill. Impact 3 is proposed permanent wetland impact for a road crossing. This road crossing is necessary because it
serves as the only access to The Glen at Hollybrook from Hollybrook Road. Impacts have been minimized by utilizing a location with an eAsting culvert
and also avoiding the larger wetland area to the west. A pipe will be utilized for a wetland connection and any subsurface hydrology. Impact 4 is
proposed permanent wetland impact necessary for grading associated with a pedestrian walking path. The location of the path was designed to the
north of the wetland W13 to minimize wetland impacts. This impact is necessary because the grade is already set to a minimum based on the paths
culvert pipe which is needed to maintain the hydrologic connection across the path. Impact 5 is a proposed road crossing with permanent and
temporary stream & wetland impacts in addition to riparian buffer impacts. This impact is necessary to provide access to the northern portion of the
property within The Meadows at Hollybrook. Headwalls have been utilized to minimize stream, wetland and riparian buffer impacts. The crossing
location was designed in this location to minimize wetland impacts and also to avoid offsite backwater issues. A cofferdam and pump around will be
utilized to allowfor continuous flow during construction activities. Impact 6 & 7 are both proposed sanitary sewer crossings that will impact a stream &
riparian buffer (#6) and riparian wetlands (#7). Impact #6 will be installed via bore and jack construction method to minimize stream impacts and will
result in temporary stream impacts. Impact #7 is an aerial sanitary sewer crossing and will result in permanent -no permanent loss wetland impacts.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:
Erosion control measures include sediment basins, silt fence, diversion ditches with rock check dams and appropriate reinforced matting, concrete
washout structures, inlet protection devices, pipe inlet and outlet protection, and construction entrances. Cofferdam and pump around are proposed
for the stream crossing at impact 5.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for impacts to Waters of the U.S. or Waters of the State?
r Yes
r No
2c. If yes, mitigation is required by (check all that apply):
W DWR
W Corps
2d. If yes, which mitigation option(s) will be used for this project?
W Mitigation bank r Payment to in -lieu fee r Permittee Responsible
program Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
EBX %use Sponsored Neu -Con Wetland & Stream Umbrella Mitigation Bank, specifically from the
Arrington Bridge III Site

3b. Credits Purchased/Requested (attach receipt and letter)
Type: Quantity:
Riparian wetland 0.58
Attach Receipt and/or letter
Neu -Con SOA - Arrington Bridge III - The Glen -The Meadows at Hollybrook.pdf 144.47KB
3c. Comments
S&EC reviewed the NCDWR Approved Mitigation Banks in NC list, there were four (4) banks listed within the 03020201 HUC that had riparian wetland
credits available. All four (4) were contacted, and all four (4) banks had credits available. Attached is a Statement of Availability letter from Resource
Environmental Solutions.
Proposed Mitigation Ratios: S&EC completed an NCWAM evaluation on Impact 2 (wetland 10) which resulted in an Overall Rating of"low' on the
NCWAM Wetland Rating Sheet (see attached with photos). Wetland 10 is a low quality system within an agricultural field with little to no habitat, low
surface water storage and retention and low water quality. Mitigation ratios were discussed with the USACE for this area and it was decided that a
0.5:1 mitigation would be offered for Impact 2. Other permanent loss wetland impacts (#'s 3, 4 & 5) are requesting a 2:1 mitigation ratio and
permanent -no permanent loss wetlands impacts (#7) at a 1:1 mitigation ratio.
6. Buffer mitigation (State Regulated Riparian Buffer Rules) - required by DWR
6a. Will the project result in an impact within a protected riparian buffer that requires buffer mitigation? If yes, you must fill out this entire form - please contact DWR for more
information.
r Yes r No
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
1. Diffuse Flow Plan
la. Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian Buffer Protection Rules?
r Yes r No
What type of SCM are you providing?
r Level Spreader
r Vegetated Conveyance (lower SHWT)
r Wetland Swale (higher SHWT)
W Other SCM that removes minimum 30 % nitrogen
r Proposed project will not create concentrated stormwater flow through the buffer
Diffuse Flow Documentation
The Glen - DA Map.pdf 430.4KB
The Meadows - DA Map.pdf 346.27KB
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?*
r Yes r No
2b. Does this project meet the requirements for low density projects as defined in 15A NCAC 02H .1003(2)?
r Yes r No
2c. Does this project have a stormwater management plan (SMP) reviewed and approved under a state stormwater program or state -approved local government stormwater
program?
r Yes r No
r WA - project disturbs < 1 acre
2d. Which of the following stormwater management program(s) apply:
W Local Government r- State
Local Government Stormwater Programs
W Phase II W NSW r USMP r Water Supply
Please identify which local government stormwater program you are using.
Wake County
Comments:
G. Supplementary Information
1. Environmental Documentation
la. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state) land?*
r Yes r No
2. Violations (DWR Requirement)

2a. Is the site in violation of DWR Water Quality 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)? *
r Yes r No
3. Cumulative Impacts (DWR Requirement)
3a. Will this project result in additional development, which could impact nearby downstream water quality?*
r Yes r No
3b. If you answered "no," provide a short narrative description.
We have reviewed the "Draft Internal Policy, Cumulative impacts and the 401 Water Quality Certification and Isolated Wetlands Programs' document
prepared by the NC Division of Water Quality on April 10, 2004, version 2.1. The draft states that many private developments are unlikely to cause
cumulative impacts, including projects such as urban in -fill, most residential subdivisions and small commercial developments as well as agricultural
and silvicultural operations. The Glen/The Meadows at Hollybrook project is a residential development. Additionally, the project is located within the
town of Wendell ETJ, therefore the adjacent properties that have potential for development will have the following regulations to protect downstream
waters: 1) the Neuse River Basin Riparian Buffer Protection regulations, these regulations require limited development within the riparian buffer area,
in addition Best Management Practices may be required that control nitrogen if diffuse flow cannot be achieved; 2) the Phase II NPDES Stormwater
Permit Program, this program includes permitting requirements for Municipal Separate Storm Sewer Systems (MS4s) in addition to post -construction
stormwater management requirements. We anticipate that the DWR Will advise us if any additional information is needed.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?*
r Yes r Nor NIA
4b. Describe, in detail, the treatment methods and dispositions (non -discharge or discharge) of wastewater generated from the proposed project. If the wastewater will be treated
at a treatment plant, list the capacity available at that plant.
Non -discharge wastewater will be generated and treated at the Lake Glad Pump Station.
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or habitat?*
r Yes r No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
r Yes r No
5d. Is another Federal agency involved?*
r Yes r No r Unknown
5e. Is this a DOT project located within Division's 1-8?
r Yes r No
5f. Will you cut any trees in order to conduct the work in waters of the U.S.?
r Yes r No
5g. Does this project involve bridge maintenance or removal?
r Yes r No
5h. Does this project involve the construction/installation of a wind turbine(s)?*
r Yes r No
Si. Does this project involve (1) blasting, and/or (2) other percussive activities that will be conducted by machines, such as jackhammers, mechanized pile drivers, etc.?
r Yes r No
If yes, please provide details to include type of percussive activity, purpose, duration, and specific location of this activity on the property.
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
The NC Natural Heritage Programs Data E)lorer Map was used to search for elemental occurrences of federally protected species listed within and
within 1-mile of the project boundaries. It was determined based on the search that there are no elemental occurrences that are listed as federally
Threatened/Endangered within or within 1-mile of the project boundaries. References: NC Natural Heritage Program. 2020. Geographic Information
System (GIS) data. NCDNCR, Raleigh, NC. Available at http://wmw.nenhp.org/. (Accessed: February 4, 2020).
5i-No blasting is currently anticipated; borings are being prepared to confirm absence/presence of rock.
Consultation Documentation Upload
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
r Yes r No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
The NOAA Habitat Conservation/Habitat Protection: National Marine Fish Service; Essential Fish Habitat Mapper website was referenced. No Essential
Fish Habitat was identified near the project.
7. Historic or Prehistoric Cultural Resources (Corps Requirement)

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?*
r Yes r No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?*
The NC State Historic Preservation Office HPOWEB GIS Service interactive map was referenced on February 1, 2020, no historic listings or study list
entries or determined eligible listings were identified within the property boundaries. Additionally, no structures exist Within the property boundaries.
7c. Historic or Prehistoric Information Upload
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain?*
r Yes r No
8b. If yes, explain how project meets FEMA requirements:
There is a 100-yr floodplain on offsite at the extreme southwest corner. All development and disturbance will occur external to the floodplain boundary.
8c. What source(s) did you use to make the floodplain determination?*
NC Flood Risk Information System Floodplain Mapping Program and confirmation from the project engineer.
Miscellaneous
Comments
NCSAM & photos attached, Phasing plan and Pre -filling form
Miscellaneous attachments not previously requested.
Phasing Plan.pdf 4.29MB
NCWAM Rating Calculator.pdf 182.69KB
Wetland 10 Site Photos. pdf 1.94MB
DWR Pre -Filing Meeting Request Form.pdf 50.22KB
Signature u
W By checking the box and signing below, I certify that:
• I have given true, accurate, and complete information on this form;
. I agree that submission of this PCN 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 PCN form.
Full Name:
Deborah E. Shirley
Signature
r �C�a�r%tley
Date
1/13/2021