20220896 Ver 2_401 Application_20230828

Staff Review
Does this application have all the attachments needed to accept it into the review process?*
Yes No
ID#* Version* 2
20220896
Is this project a public transportation project?* Yes
No
Reviewer List: * Rebecca Chandler:rebecca.chandler
Select Reviewing Office: * Winston-Salem Regional Office - [phone]
Does this project require a request for payment to be sent?
Yes
No
How much is owed?* $240.00
$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: * For the Record Only (Courtesy Copy)
New Project
Modification/New Project with Existing ID
More Information Response
Other Agency Comments
Pre -Application Submittal
Re-Issuance\Renewal Request
Stream or Buffer Appeal
Pre -Filing Meeting Date Request was submitted on:
4/19/2022
Project Contact Information
Name: S. Paul Petitgout
Who is submitting the information?
Email Address: [e-mail]
Project Information
Existing ID #: Existing Version:
20220896 1
20170001(no dashes) 1
Project Name: Long Creek Village Site - City of Winston Salem, Forsyth County, NC
Is this a public transportation project?
Yes
No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
Yes No Unknown
Is this project connected with ARPA funding?
Yes No
County (ies)
Forsyth
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach document
PCN - REVISED Long Creek Village Site_Forsyth
19.27M B
Cou nty_N C_8-28-23. pdf
Only pdf or kmz files are accepted.

Describe the attachments or
comments:
The purpose in this re -permitting effort is that additional impacts are required to complete the project as
NCDOT insisted on changes to the project's road crossings so that geo-grid could be removed from the right-
of-way at the crossing locations. This increased the amount of impact required to complete the project. Sue
Homewood was the original project manager for this project.
Should you have any questions, please contact me at [e-mail] or 803-992-0910
Sign and Submit
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:
S' ��rul�rYil9ait
Submittal Date: 8/28/2023
Is filled in automatically.