20230491 Ver 1_Pre-Construction Notification (PCN) Form_Old Milburnie Village_Updated 06-21-2023_20230627

DWR
IDIOM— of Water Resources
Updated PCN per USACE &
NCDWR comments dated 4/28/23
and 5/26/23
D. Shirley
6/23/2023
Pre -Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
April 13, 2022 Ver 4.3
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.
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 document and you can print a copy of the form.
Below is a link to the online help file.
https://edocs.deq.nc.govfVVaterResources/0/edoc/624704/PCN / 20Help/ 20File/ 202018-1-30.pdf
A. Processing Information O
Pre -Filing Meeting Date Request was submitted on:
6/9/2022
If this is a courtesy copy, please fill in this with the submission date.
Is this project connected with ARPA funding?"
Q Yes No
County (or Counties) where the project is located:"
Wake
Is this a NCDMS Project"
Q Yes QQ No
Click Yes, only if NCD MS is the applicant or co -applicant.
DO NOT CHECK YES, UNLESS YOU ARE DMS OR CO -APPLICANT.
Is this project a public transportation project?"
Q Yes QQ No
This is any publicly funded by municipal,state or federal funds road, rail, airport transportation project.
1 a. Type(s) of approval sought from the Corps:"
12 Section 404 Permit (wetlands, streams and waters, Clean Water Act)
❑ Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
Has this PCN previously been submitted?"
Q Yes
QQ No
1 b. What type(s) of permit(s) do you wish to seek authorization?"
Q Nationwide Permit (NWP)
❑ Regional General Permit (RGP)
❑ Standard (IP)
1c. Has the NWP or GP number been verified by the Corps?"
Yes ' No
Nationwide Permit (NWP) Number:
Nationwide Permit (NWP) Number:
NWP Numbers (for multiple NWPS):
NWP 18 (SCM grading)
List all NVV numbers you are applying for not on the drop down list.
1 d. Type(s) of approval sought from the DWR:
check all that apply
0 401 Water Quality Certification - Regular
❑ Non-404 Jurisdictional General Permit
❑ Individual 401 Water Quality Certification
29 - Residential Developments
18 - Minor Discharges
❑ 401 Water Quality Certification - Express
12 Riparian Buffer Authorization
le. Is this notification solely for the record because written approval is not required?

For the record only for DWR 401 Certification:
For the record only for Corps Permit:
Q Yes OQ No
O Yes OQ No
1f. Is this an after -the -fact permit application?"
Yes v No
1g. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
If so, attach the acceptance letter from mitigation bank or in -lieu fee program.
O Yes Q No
Acceptance Letter Attachment
Click the upload button or drag and drop files hereto attach document
FILE TYPE MUST BE PDF
1 h. Is the project located in any of NC's twenty coastal counties?"
Yes No
1j. Is the project located in a designated trout watershed?"
O Yes OO No
Linkto trout information: http://www.saw.usace.army.miI/Missions/Regulatory-Permit-Program/Agency-Coordination/Trout.aspx
B. Applicant Information
la. Who is the Primary Contact?"
Deborah Shirley
1c. Primary Contact Phone:"
1 b. Primary Contact Email" (xxx)xxx-xxxx
[e-mail] [phone]
1d. Who is applying for the permit?"
_ Owner ❑ Applicant (other than owner)
(Check all that apply)
1e. Is there an AgentlConsultant for this project?"
U Yes (_) No
2. Owner Information
2a. Name(s) on recorded deed:"
Trigate-Suncrest Brio West, LLC
2b. Deed book and page no.:
DB: 019117, DP: 02501, DB: 019117, DP: 01794,DB: 019117, DP: 00922
2c. Contact Person:
(for Corporations)
Mark McAuley
2d.Address*
Street Address
2701 E. Camelback Rd Ste 180
Address Line 2
City
State / Province / Region
Phoenix
AZ
Postal /Zip Code
Country
85016
USA
2e. Telephone Number:"
(xxx)xxx-xxxx
[phone]
2f. Fax Number:
2g. Email Address:"
[e-mail]
4. Agent/Consultant (if applicable)
4a. Name:"
Deborah Shirley

4b. Business Name:
(if applicable)
Soil & Environmental Consultants, PA
4c. Address"
Street Address
8412 Falls of Neuse Road, Suite 104
Address Line 2
City
Raleigh
Postal /Zip Code
27615
4d. Telephone Number:"
[phone]
4f. Email Address:"
[e-mail]
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:"
Old Milburnie Village
1b. Subdivision name:
(if appropriate)
1c. Nearest municipality/town:"
Knightdale
2. Project Identification
State / Province / Region
NC
Country
USA
4e. Fax Number:
[phone]
(xxx)xxx-xxxx
2a. Property Identification Number:
2b. Property size:
(tax PIN or parcel ID)
(in acres)
1745872891, 1745972793, and 1755076493
92.2
2c. Project Address
Street Address
2824 Old Milburnie Road
Address Line 2
City
State / Province / Region
Knightdale
NC
Postal /Zip Code
Country
27545
USA
2d. Site coordinates in decimal degrees
Please collect site coordinates in decimal degrees. Use between 4-6 digits (unless you are using a survey -grade GPS device) after the decimal place as appropriate, based on how the location was
determined. (For example, most mobile phones with GPS provide locational precision in decimal degrees to map coordinates to 5 or 6 digits after the decimal place.)
Latitude:" Longitude:"
-78.4918
-77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:"
UT to Beaverdam Creek
3b. Water Resources Classification of nearest receiving water:"
QNSW
Surface Water Lookup
3c. What river basin(s) is your project located in?"
Neuse
3d. Please provide the 12-digit HUC in which the project is located."
030202010705
River Basin Lookup
U
lJ
l^J

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:"
Existing conditions onsite consists of forested land with some field areas. There are ten wetlands (WA, WB, WBD, WBA, WZ, WY, WX, WW, WBB, & WBC) and 2 streams (SA & SB)
within the property boundaries. General land use in the vicinity of the project consists of forested land and rural residential. Old Crews Road bounds the road to the East and Old Milburnie
Road bounds the property to the west.
4b. Have Corps permits or DWR certifications been obtained for this project (including all prior phases) in the past?"
O Yes OO No O Unknown
4f. List the total estimated acreage of all existing wetlands on the property:
Approximately 2.11 Acres
4g. List the total estimated linear feet of all existing streams on the property:
(intermittent and perennial)
Approximately 3,409 LF
4h. Explain the purpose of the proposed project:"
The purpose of this project is to construct a 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 the construction of a residential development consisting of single family lots and multi -family units, including but not limited to, roadway infrastructure,
residential lots, utilities, SCMs, and amenities. Specifically there are impacts associated with road crossings, seq twy so­r and stormwater devices. Equipment typically used for
construction and earthwork such as backhoes, bulldozers, excavators, graders, pavers etc. will be utilized for this project.
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or proposed impact areas?"
OQ Yes No O Unknown
Comments:
5b. If the Corps made a jurisdictional determination, what type of determination was made?"
(p) Preliminary O Approved U Not Verified _ Unknown " N/A
Corps AID Number:
Example: SAW-2017-99999
SAW-2018-01443
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known): Chris Hopper & Preston Butler
Agency/Consultant Company: Carolina Ecosystems, Inc
Other:
5d. List the dates of the Corp jurisdiction determination or State determination if a determination was made by the Corps or DWR.
NCDWR: Site visit and determination made by Ray Milosh and issued on August 16, 2018 (NBRRO #18-279). Additional parcel and determination made by Cheng Zhang and issued on
July 14, 2021 (NBRRO #21-065).
USACE: SAW-2018-01443, email verified on May 18, 2021 by Same Dailey.
6. Future Project Plans
6a. Is this a phased project?"
OO Yes O No
6b. If yes, explain.
For construction purposed, project is broken into 3 phases. All phases are shown within the property boundaries.
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? This includes other
separate and distant crossing for linear projects that require Department of the Army authorization but don't require pre -construction notification.
It is my understanding that there are no intended future phases beyond the property boundaries shown. Therefore, no additional NWP, Regional General Permits, or IF are anticipated.
D. Proposed Impacts Inventory
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
Wetlands M Streams -tributaries M Buffers
Open Waters Q Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
"W." will be used in the table below to represent the word "wetland".
v

2a1 Reason*(?)
2b. Impact type*(?)
pe
rTy
2d. W. name"
2e. Forested"
2f. Type of Junsdicition*
2g. Impact
area*
Impact 1
OI711tteCl
Impact4
Sanitary Sewer
Crossing- Permanent -no
Permanent Loss
SCM Grading
P
P
Headwater Forest
Headwater Forest
WV
WA
Yes
Yes
Both
Both
Q
acres
0.003
(acres)
Impact4
Access onstruction
T
Headwater Forest=�WA
Yes
Both
0(Ocres)
2g. Total Temporary Wetland Impact
0.015
2g. Total Permanent Wetland Impact
0.003
2g. Total Wetland Impact
0.018
2i. Comments:
Total permanent loss wetland = 0.003 acres; - Total temporary wetland impacts = 0.015 acres.
Temporary wetland impacts will be brought back to pre -construction contours and the existing adjacent wetland source will assist in the restoration of the
wetland vegetation.
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this question for all stream sites impacted.
"S." will be used in the table below to represent the word "stream".
3a. Reason for impact* (?)
3b.lmpact type*
3c. Type of impact*
3d. S. name*
3e. Stream Type*
3f. Type of
width*
3h. Impact
(?)
Jurisdiction*
length*
S1
Impact 2 - Road Crossing:
Permanent
Culvert
Stream B
Perennial
Both
3
75
Culvert & Headwalls
Average (feet)
(Ilnear feet)
g2
Impact 2 - Road Crossing:
Permanent
Other
Stream B
Perennial
Both
5
23
Dissipator Pad (Permanent-
Average (feet)
pinear feet)
no permanent loss)
S3
Impact 2 - Road Crossing:
Temporary
Other
Stream B
Perennial
Both
3
44
Construction Access
Average (feet)
Qinearfeet)
S4
Impact 3 - Road Crossin
p 9
Permanent
Culvert
Stream A
Perennial
Both
5
83
Culvert & Headwalls
Average (feet)
pinear feet)
SS
Impact 3 - Road Crossing:
Permanent
Other
Stream A
Perennial
Both
5
26
Dissipator Pad (Permanent-
Average (feet)
pinear feet)
no permanent loss)
S6
Impact 3 -Road Crossing:
Temporary
Other
Stream A ==[Both
5
37
Construction Access
Average (feet)
Qinearfeet)
** All Perennial or Intermittent streams must be verified by DWR or delegated local government.
3i. Total jurisdictional ditch impact in square feet:
3i. Total permanent stream impacts:
207
3i. Total temporary stream impacts:
81
3i. Total stream and ditch impacts:
288
3j. Comments:
Total permanent loss stream = 158 LF (0.013 acres); Total permanent -no permanent loss stream = 49 LF (0.005 acres); Total temporary stream = 81 LF
(0.007 acres); Temporary stream impacts will be brought back to pre -construction stream bed elevations and the stream banks will be stabilized.
6. Buffer Impacts (for DWR)
If project will impact a protected riparian buffer, then complete the chart below. Individually list all buffer impacts below.

6a. Project is in which protect basin(s)?"
Check all that apply.
Neuse ❑ Tar -Pamlico
Catawba ❑ Randleman
Goose Creek ❑ Jordan Lake
❑ Other
6b. Impact Type"(')
Impact 2 -Road Crossing
6c. Per or Temp"(') 11
P
6d. Stream name"
Stream B
6e. Buffer mitigation required?"
No
6f. Zone 1 impact"
8,279
(square feet)
6g. Zone 2 impact"
4,103
(square feet)
Impact 3 - Road Crossing
P
Stream A
No
8(786
(square feet)
4,718
(square feet)
6h. Total buffer impacts:
Zone 1 Zone 2
Total Temporary impacts: 0.00 0.00
Zone 1
Zone 2
Total Permanent impacts: 17,065.00
8,821.00
Zone 1
Zone 2
Total combined buffer impacts: 17,065.00
8,821.00
6i. Comments:
E. Impact Justification and Mitigation
1. Avoidance and Minimization
la. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:"
An environmental consulting firm completed a wetland delineation and Neuse River Buffer evaluation for the property in order to identify natural
resources so that impacts could be avoided and minimized to the maximum extent practicable. .
^%. Impact Area 2 is proposed road crossing a perennial stream. Proposed impacts include permanent (i.e. culvert &
headwalls), permanent -no permanent loss (i.e. dissipator pad) and temporary (i.e. construction access) stream impacts, and associated riparian buffer
impacts. Per the project engineer, the connection to Brilliant Drive is part of the Knightdale comprehensive transportation plan. In section 11.3.E.3 of
Knightdale's UDO it is stated that vehicular connections from adjacent property must be utilized unless the Land Use Administrator deems the
connection impractical due to topographical conditions, environmental constraints, property shape, or property accessibility. During the preliminary
project review with Knightdale's Development Review Committee, the committee stated the road extension between Brilliant Drive and the site needs to
be included in the design. The connection is also necessary for EMS and fire access safety purposes. Stream and riparian buffer impacts have been
minimized by utilizing head walls and retaining walls at the crossing, and by designing the crossing at a near perpendicular angle. Impact area 3 is
proposed road crossing over a perennial stream. Proposed impacts include permanent (i.e. culvert & headwalls), permanent -no permanent loss (i.e.
dissipator pad) and temporary (i.e. construction access) stream impacts, and associated riparian buffer impacts. This crossing is necessary to provide
access to the project from Old Crews Road. Stream and riparian buffer impacts have been minimized by utilizing head walls and retaining walls at the
crossing, and by designing the crossing at a near perpendicular angle. Impact area 4 is a proposed wetland impact for a stormwater control measure
(SCM). Proposed impacts include permanent and temporary wetland impacts. Per the project engineer, the SCM is at the lowest spot in the drainage
area and is at the minimum required surface area to treat the drainage area. SCM grading has also been designed at the most allowable slope to reduce
encroachment into the wetland area. The SCM is restricted from any upland alternative due to site topography, lot layout, and an alley. A NWP 18 is
being requested for this proposed impact. Temporary stream impacts will be brought back to pre -construction stream bed elevations and the stream
banks will be stabilized. Temporary wetland impacts will be brought back to pre -construction contours and the existing adjacent wetland source will
assist in the restoration of the wetland vegetation.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:"
Per the project engineer: silt fence, silt fence outlets, check dam, sediment trap, skimmer basin, diversion ditch
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?
Q Yes
No
2b. If this project DOES NOT require Compensatory Mitigation, explain why:
Permanent loss stream impacts are less than 0.02 acres, permanent loss wetland impacts are less than 0.10 acre. Impacts have been avoided to the maximum extent practicable.
Therefore compensatory mitigation in the form of mitigation payment has not been proposed.
t.J
NC Stream Temperature Classification Maps can be found under the Mitigation Concepts tab on the Wilmington District's RIBITS website.

F. Stormwater Management and Diffuse Flow Plan (required by DWR)
v
*** Recent changes to the stormwater 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 within one of the NC Riparian Buffer Protection Rules?
Yes No
1 b. All buffer impacts and high ground impacts require diffuse flow or other form of stormwater treatment. If the project is subject to a state implemented riparian buffer protection program,
include a plan that fully documents how diffuse flow will be maintained.
All Stormwater Control Measures (SCM)s must be designed in accordance with the NC Stormwater Design Manual. 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)
Q Other SCM that removes minimum 30% nitrogen
❑ Proposed project will not create concentrated stormwater flow through the buffer
(check all that apply)
For a list of options to meet the diffuse flow requirements, click here.
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?"
Q Yes OQ No
2b. Does this project meet the requirements for low density projects as defined in 15A NCAC 02H .1003(2)?"
Q Yes OQ No
To look up low density requirement click here 15A NCAC 02H .1003(2).
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?"
OO Yes O No
O N/A - project disturbs < 1 acre
Hint: projects that have vested rights, exemptions, or grandfathenng from state or locally implemented storm —ter programs or projects that satisfy state or locally -implemented stonnwater programs through use of community in -lieu programs should answer
no to this question.
2d. Which of the following stormwater management program(s) apply (check all that apply):"
0 Local Government ❑ State
If you have a local government approval please include the SMP on their overall impact map.
Local Government Stormwater Programs"
Q Phase II Q NSW
� USMP ❑ Water Supply
Please identify which local government stormwater program you are using."
Town of Knightdale
Comments:
4 wet ponds, 1 bioretention area
G. Supplementary Information
1. Environmental Documentation
la. Does the project involve an expenditure of public (federal/state/local) funds orthe use of public (federal/state) land?"
Yes 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)?"
Yes No
3. Cumulative Impacts (DWR Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in additional development, which could impact nearby downstream water quality?"
Yes 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 Old Milburnie Village project is a residential development. Additionally, the project is located within the Town of Knightdale
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?"
QQ Yes O No O N/A
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; sewage will discharge into the existing SS outfall along the north side of the site and be treated by the Town of Knightdale WWTP.*
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?"
Yes No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?"
Yes No
5c. If yes, indicate the USFWS Field Office you have contacted.
Raleigh
5d. Is another Federal agency involved?"
O Yes No OQ Unknown
5e. Is this a DOT project located within Division's 1-8?"
O Yes OO No
5f. Will you cut any trees in order to conduct the work in waters of the U.S.?"
OO Yes O No
5g. Does this project involve bridge maintenance or removal?"
Yes OO No
Link to the NLEB SLOPES document: http://saw-reg.usace.army.mil/NLEB/1-30-17-signed_NLEB-SLOPES&apps.pdf
5h. Does this project involve the construction/installation of a wind turbine(s)?*"
O Yes OO No
5i. 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.?"
O Yes OO No
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?"
S&EC completed a Threatened & Endangered Species Report, to include a Self -Certification letter through the US Fish & Wildlife Service (USFWS), a
query through the NC Natural Heritage Program database, and an official Species List through the iPac. A formal request was sent to the USFWS on
April 26, 2021. S&EC received response from USFWS on June 28, 2021 that they concurred with the determinations made by S&EC that the proposed
actions is not likely to adversely affect any federally -listed endangered or threatened species, their formally designated critical habitat, or species
currently proposed for listing under the Endangered Species Act (ESA). Please see attached S&EC Threatened & Endangered Species report and
correspondence from USFWS.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?"
O Yes 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)
Linkto the State Historic Preservation Office Historic Properties Map (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)?"
0 Yes OQ 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 March 15, 2021. A request for Environmental
Review was submitted to SHPO requesting comments. A SHPO response letter was provided on June 29, 2021 indicating that they are not aware of any
historic resources that would be affected by the proposed project. Please see attached SHPO letter ER 21-1191
8. Flood Zone Designation (Corps Requirement)
Link to the FEMA Floodplain Maps: https:Hmsc.fema.gov/portal/search
8a. Will this project occur in a FEMA-designated 100-yearfloodplain?"
QQ Yes No
8b. Ifyes, explain how project meets FEMA requirements:
There is a small portion of the project within the FEMA floodway, however there are no proposed impacts within this FEMA floodway.
8c. What source(s) did you use to make the floodplain determination?"
NC Flood Risk Information System Floodplain Mapping Program
Miscellaneous
Comments
u
Please use the space below to attach all required documentation or any additional information you feel is helpful for application review. Documents should be combined into one file when
possible, with 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 document
PCN Attachments —Old Milburnie Village.pdf 19.33MB
File must be PDF or KMZ
Signature
Q By checking the box and signing below, I certify that:
• The project proponent hereby certifies that all information contained herein is true, accurate, and complete to the best of my knowledge and belief', and
• 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.
• have given true, accurate, and complete information on this form;
• agree that submission of this PCN form is a "transaction" subjectto 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 Shirley
Signature"
Date
3/30/2023
u