20140762 Ver 6_401 Application_20210923

Staff Review Form Is
Updated September
Staff Review
Does this application have all the attachments needed to accept it into the review process?*
r Yes r No
ID#* Version* 6
20140762
Is this project a public transportation project?* r Yes
r No
Is this a DOT r Yes r 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?
r
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
r More Information Response
r Other Agency Comments
r Pre-Application Submittal
r Re-Issuance\Renewal Request
r Stream or Buffer Appeal
Pre-Filing Meeting Information
Pre-Filing meeting request information is not needed for this project.
Project Contact Information
.......................................................................................................................................................................................................................................................................................................................................................................................................
Name: Michael Turchy
Who is subrritting the inforrration?
Email Address: [e-mail]
Project Information
.......................................................................................................................................................................................................................................................................................................................................................................................................
Existing ID M Existing Version:
20140762 5
20170001(no dashes) 1
Project Name: R-2915 US 221 Widening from US 421 to US 221 Bus/NC 88 in Jefferson
Is this a public transportation project?
r Yes
r No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
r Yes r No r Unknown
TIP#: WBS#:
R-2915 34518.1.F R6
(Applies to DOT projects only)
County(ies)
Ashe
Watauga
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach docurrent
R-2915 Modification Ashe-Watauga September 24
2M6
2021.pdf
Only pdf or Iv17 files are accepted.

Describe the attachments
or comments:
Permit Modification Request Package: Cover letter and drawings.
Sign and Submit
FJ Bychecking the boxand signing box below, I certifythat:
■ 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:
mv�T"
Submittal Date: Is filled in autorretically.