20211404 Ver 1_401 Application_20211003

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*
20211404
Is this project a public transportation project?* r Yes
r No
Is this a DOT r Yes r No
project?*
Reviewer List:* Hannah Sprinkle:eads\hhsprinkle
Select Reviewing Office:* Wilmington 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
Project Contact Information
Name: Mason Herndon
Who is subrritting the information?
Email Address: [e-mail]
Project Information
Project Name: Intersection Improvements at Hickman Rd and US Hwy 17
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#:
W-5703H 44849.1.8
(Applies to DOT projects only)
County(ies)
Brunswick
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach document
Brunswick W-5703H Courtesy
9.83MB
Notification_signed.pdf
Only pdf or krre files are accepted.
Describe the attachments
or comments:
Cover letter,vicinity map, PJD maps, SMP, permit drawings and WIS.
Sign and Submit
V By checking the box and 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');
■ 1 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:
61
Submittal Date: Is filled in autorratically.