20211243 Ver 1_New Project Form_20210907

Staff Review Form
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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
20211243
Is this project a public transportation project?* (' Yes
r No
Is this a DOT r Yes 6' No
project?*
Reviewer List:* Dave Wanucha:eads\djwanucha
Select Reviewing Office:* Winston-Salem Regional Office-[phone]
Does this project require a request for payment to be sent?*
l;
Yes
C'
No
How much is ( $240.00
owed?* r $570.00

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
✓ Modification/New Project with Existing ID
✓ More Information Response
✓ Other Agency Comments
✓ Pre-Application Submittal
✓ Re-Issuance\Renewal Request
r Stream or Buffer Appeal
Pre-Filing Meeting Information
Before submitting this form please ensure you have submitted the Pre-Filing Meeting Request Form as we will not
be able to accept your application without this important first step.The Pre-Filing Meeting Request Form is used in
accordance with 40 C.F.R. Section 121.4(a)"At least 30 days prior to submitting a certification request,the project
proponent shall request a pre-filing meeting with the certifying agency"and in accordance with 40 C.F.R. Section
121.5(b)(7),and (c)(5)all certification requests shall include documentation that a pre-filing meeting request was
submitted to the certifying authority at least 30 days prior to submitting the certification request.Click here to read
more information on when this form is needed prior to application submission or here to view the form.
Attach documentation of Pre-Filing Meeting Request here:
DWR_SEPA Comments_BRPrkway_Bridge.pdf 1.5MB
Date for Meeting Request 5/16/2019
ID# 20211243 Version 1
Project Contact Information
Name: Kristi Lynn Carpenter for Kevin Rose
Who is submitting the inforrration?
Email Address: [e-mail]
Project Information
Existing ID#: Existing Version:
20211243 1
20170001(no dashes) 1
Project Name: TPB FWHA-Laurel Fork Bridge Replacement-Blue Ridge Parkway
Is this a public transportation project?
a Yes
✓ No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
✓ Yes r No r Unknown
TIP#: WBS#:
(Applies to DOT projects only)

County(ies)
Ashe
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach docurrent
PCN WITH ATTACHMENTS BLRI 2D17reduced.pdf 64.13MB
BLRI 2D17 401 permit cover letter.pdf 216.13KB
Only pa or krrz files are accepted.
Describe the attachments
or comments:
Original submitted via email to reviewer on 9/2/2021.Application received by administrative staff 9/7/2021.
Sign and Submit
.......................................................................................................................................................................................................................................................................................................................................................................................................
17 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:
Lr r L7 4Aaee renolvl 4!.
Submittal Date: Is filled in automatically.