20171506 Ver 1_PCN Form Submission_20171127

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 11/27/2017 9:04:54 AM (Start Event)
Accept by Carpenter,Kristi 11/27/2017 2:42:28 PM (DOT Initial Review)
• The task was assigned to Carpenter,Kristi . The due date is: November 30, 2017 5:00 PM
11 /27/2017 9:05 AM

�� �
6fvlslaa of Water Resources
Pre-Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
November 25, 2017 Ver 2.1
*
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 ans�red.
Below is a link to the online help file.
http://edocs.deq.nc.gov/WaterResources/0/doc/603610/Page1.aspx
A. Processing Information
County (or Counties) where the project is located:*
Mecklenburg
Is this project a public transportation project? (?)
r Yes C' No
Is this a NCDOT Project?
C� Yes C' No
(NCDOT only) T.I.P. or state project number:
U-6084
WBS #
47618.1.1
(for NCDOT use only)
1a. Type(s) of approval sought from the Corps:
ri Section 404 Permit (wetlands, streams and waters, Clean Water Act)
r Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
1b. What type(s) of permit(s) do you wish to seek authorization?
rJ Nationwide Permit (NWP)
r Regional General Permit (RGP)
Nationwide Permit (NWP) Number:
NWP Number Other:
n/a
List all MNnurrbers you are applying for not on the drop down list.
14 - Linear transportation
1c. Type(s) of approval sought from the DWR:*
check all that apply
rJ 401 Water Quality Certification - Regular
� Non-404 Jurisdictional General Permit
r 401 Water Quality Certification - Express
r Riparian Buffer Authorization

*
1d. Is this notification solelyfor the record because
written approval is not required?
For the record only for DWR 401 Certification: C' Yes C•' No
For the record only for Corps Permit: C' Yes r No
1e. Is payment into a mitigation bank or in-lieu fee program proposed for mitigation of impacts?
If so, attach the acceptance letter from rritigation bank or in-lieu fee program
C•' Yes C' No
Acceptance Letter Attachment
qick the upload button or drag and drop files here to attach docurrent
U-6804 - Division 10 - STR - CT 01.pdf 58.72K6
FlLE TYFE MJST BE FDF
1f. Is the project located in any of NC's twenty coastal counties?*
C' Yes C•' No
1h. Is the project located in a designated trout watershed?*
G No
C' Yes
Link to trout information: http://w�nn�v.saw.usace.army.mil/Missions/Regulatory-Permit-PrograrrUAgency-Coordination/Trout.aspx
6. Applicant Information
1a. Who is the Primary Contact?*
Larry Thompson
1b. Primary Contact Email:*
[e-mail]
1c. PrimaryContact Phone:*
(xxx)xxx-xxxx
[phone]
1d. Who is applying for the permit?
I7 Owner r Applicant (other than owner) r AgenUConsultant
(Check all that apply)
� 2. Owner I nformation
2a. Name(s) on recorded deed:
i North Carolina Department of Transportation
2b. Deed book and page no.:
n/a
2c. Responsible party:
(for Corporations)
n/a
2d.Address

Street Address
Highway Division 10
Address Line 2
716 W Main Street
a�
Albemarle
Fbstal / Zip Code
28001
2e. Telephone Number:
(xxx)xxx-xxxx
[phone]
2f. Fax Number:
[phone]
(xxx)xxx-xxxx
2g. Email Address:*
[e-mail]
State / Rovince / f�gion
NC
Country
USA
C. Project Information and Prior Project History
1. Project Information
1a. Name of project:*
U-6084 Brookshire Boulevard Improvements
1b. Subdivision name:
(if appropriate)
n/a
1c. Nearest municipality/town:*
Charlotte NC
1d. Driving directions*
If it is a new project and can not easily be found in a C� rrapping system Rease provide directions.
From I-485 in Charlotte: Take exit 16 (NC-16 f�UBrookshire Boulevard) and head north from the exit ramp. Project extends from I-485 through
the intersection with Mt. Holly-Huntersville Road
2. Project Identification
2a. Property Identification Number:
(tax RN or parcel ID)
n/a
2b. Propertysize:
(in acres)
29.6
2c. Project Address
Street Address
Brookshire Boulvard and Mt. Holly-Huntersville Road
Address Line 2
��
Charlotte
Fbstal / Zip Code
28216
State / Rovince / F�gion
NC
Country
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 howthe location was determined. (For e�mple, 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:*
35.325675 -80.94522
ex:34.208504 -77.796371
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
UT to Long Creek / UT Mountain Island Lake
3b. Water Resources Classification of nearest receiving water:*
WS-IV / WS-I, B; CA
Surface Water Lookup
3c. What river basin(s) is your project located in?*
Catawba
River Basin Lookup
4. Project Description
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:*
The property along Brookshire Boulevard is primarily in commercial and residential development. The adjacent
Riverbend site development has been cleared and graded but structures have not yet been built. A Duke Energy
i transmission line runs parallel to and on the east side of Brookshire Boulevard for the length of the project area.
Some forested remnants remain between areas of development.
4b. Attach an 8 1/2 X 11 excerpt from the most recent version of the USGS topographic map indicating the location of the project site. (for
DWR)
qick the upload button or drag and drop files here to attach docurrent
U-6084_usgs_ma p_8-5x11. pdf
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1.1 MB
4c. Attach an 8 1/2 X 11 excerpt from the most recent version of the published County NRCS Soil Survey map depicting the project site.
(for DWR)
C7ick the upload button or drag and drop files here to attach docurrent
U-6084_soils_pu bl ished_8-5x11. pdf
Fle type rrust be pdf
4d. List the total estimated acreage of all existing wetlands on the property:
0.03
4e. List the total estimated linear feet of all existing streams on the property:
(interrrittent and perennial)
447
4f. Explain the purpose of the proposed project:
2.27M6

Brookshire Boulevard is a"road of regional significance" that connects northwestern Mecklenburg County to
Charlotte's Center City and to Gaston, Lincoln and Catawba counties. Traffic volumes have increased over the
years as the surrounding areas have developed. The intersection of Brookshire Boulevard and Mt. Holly-
Huntersville Road was identified in the 2002 Brookshire Boulevard/I-485 Area Plan (City of Charlotte) as a major
traffic concern. Conversion to a grade separation intersection was proposed as a solution at the time but not
implemented. Multiple congestion management projects have been completed in this location but were limited in
scope and funding.
Traffic conditions have continued to deteriorate since the time of that Area Plan and a new Corning Optical
Communications facility is slated to be built within the adjacent Riverbend Village site development. The e�ected
addition of 1,800 employees will further exacerbate the traffic loads in the area. Site constraints and epsting
surrounding development have precluded grade separation and a continuous flow intersection (CFI) has been
designed for the Brookshire Boulevard/Mt. Holly-Huntersville intersection. The continuous flow intersection uses
offset left turn lanes and signal timing to allow additional simultaneous lane movements. The footprint of a CFI is
much smaller than a similar grade separation intersection allowing for less impacts to the ebsting land use.
4g. Describe the overall project in detail, including the type of equipment to be used:
The continuous flow intersection includes additional crossover left turn lanes to be added to Brookshire Boulevard
to accommodate left turns onto Mt. Holly — Huntersville Road from either direction. No impacts to jurisdictional
waters are e�ected as part of the CFI section of the proposed project.
In order to achieve appropriate level of service (LOS) for the proposed intersection, a right in / right out access
road is required into the Riverbend Village site development. That access is known as "Access D" in this permit
and is the location of permanent impacts proposed within this permit.
Placement of the access road to the site development from Brookshire Boulevard was determined by traffic
analysis. The right turn movement from northbound Brookshire to westbound Mount Holly-Huntersville Road
required 400 feet of storage. The site access road was placed directly south, adjacent to the taper for this
storage. This placement also provides the 175 feet of storage needed for the right turn movement into the site
access road while not interfering with the I-485 ramp movements.
The addition of a right-hand turn lane from Brookshire Boulevard onto Access D includes extending the existing
36" pipe under Brookshire Boulevard (intermittent Stream E— 2017 Impact Site 1). Access D also crosses
perennial Stream C(2017 Impact Site 2). As described in Section 65b of this permit application, a portion of 2017
Impact Site 2 was included as part of the adjacent Riverbend Village site development (2015 NWP 39). An access
road was not planned during the site development permitting and the old impact was undertaken for overall site
grading purposes. The e�sting fill and drainpipe will be removed and replaced with a 30" RCP.
Typical roadway construction equipment will be used including backhoes, bulldozers, pans, pavers, rollers,
sheepsfoot, and dumptrucks. All appropriate sediment and erosion control measures will be implemented and
monitored throughout construction.
4h. Please upload project drawings for the proposed project.
C7ick the upload button or drag and drop files here to attach docurrent
U-6084_Permit_Drawings.pdf 1.4MB
U6084_Brooksh ire_Blvd_F ULL_65_Percent_Plans. pdf 9.2MB
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5. Jurisdictional Determinations
Sa. Have the wetlands or streams been delineated on the propertyor proposed impact areas?*
C� Yes C' No C' Unknown
Comme nts:
Partial site delineation approved in 2015.
5b. If the Corps made a jurisdictional determination, what type of determination was made? *
C' Preliminary C•' Approved C' Unknown C' f�UA
Corps AID Number:
6carrple: SAV�2017-99999
SAW-2015-01564

Sc. If 5a is yes, who delineated the jurisdictional areas?
Name (if known):
Agency/Consultant Company:
Othe r:
C. Huysman
Huysman & Bandy, Inc.
n/a
Sd. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
SAW-2015-01564 issued 8/10/2015 covers Riverbend Site Development portion of the project site. Additional areas along Brookshire
Boulevard delineated by P. Ferral and A. Coleman, Stantec, in 2017 and included with this permit as a PJD request.
5d1. Jurisdictional determination upload
C7ick the upload button or drag and drop files here to attach docurrent
SAW-2015-01564_2014_JD.pdf
i U-6084_2017_PJD.pdf
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6. Project History
1.02M6
28.23MB
6a. Have permits or certifications been requested or obtained for this project (including all prior phases) in the past?*
C� Yes
C' No
!' Unknown
6b. If yes, please give the DWR Certification number or the Corps Action ID (exp. SAW-0000-00000).
The adjacent Riverbend Village site development received a NWP 39 permit in 2015 (SAW-2015-01564). That
permit included 841f of perennial stream impact (2015 site 1) as well as 651f of perennial stream impact to another
perennial stream (2015 Site 2) on the east side of the site development. 2015 Site 1 impacts v�re completed and
2015 Site 2 were not, and the permit e�ired with the e�iration of the 2012 Nationwide Permits.
As described above, the improvements to Brookshire Boulevard include installation of an access road (Access D)
at the location of the 2015 Site 1 impact (2017 Site 2 Impact). That impact is included within this permit since a
culvert will be installed at that location including and beyond the previous impact.
Project History Upload
Gick the upload button or drag and drop files here to attach docurrent
160105 mtholly issued permit_and_application.pdf
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7. Future Project Plans
7a. Is this a phased project?*
C' Yes C•' No
3.49M6
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.
no
D. Proposed Impacts Inventory
1. Impacts Summary
1a. Where are the impacts associated with your project? (check all that apply):
r Wetlands
r Open Waters
rJ Streams-tributaries
r Pond Construction
r Buffers
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.

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.
3a. Site #- Reason 3b.lmpact 3c. Type of 3d. Stream name *
for impact* type* impact*
Site 1(a) P Culvert UT Long Creek (SE)
N�p label (e.g. 13�ad F�rrrenent (P�
trossing 1) or Terrporary
��
Site 1(b) P Stabilizati UT Long Creek (SE)
N�p label (e.g. 13�ad F�rrrenent (F) On
trossing1) orTerrporary
��
Site 1(c) T Stabilizati UT Long Creek (SE)
Nt�p label (e.g. 13�ad F�rrrenent (P� On
trossing 1) or Terrporary
��
Site 2(a) P Culvert UT Long Creek (SC)
N�p label (e.g. 13�ad F�rrrenent (F)
trossing 1) or Terrporary
��
Site 2(b) P Stabilizati UT Long Creek (SC)
N�p label (e.g. I�ad F�rrranent (P� on
Qossing 1) or Terrporary
��
Site 2(c) T Stabilizati UT Long Creek (SC)
N�p label (e.g. 13�ad F�rrrenent (P� On
Qossing 1) or Terrporary
��
3e. Stream Type * 3f. 3g. Stream 3h. Impact
Jurisdictior�idth* length*
type *
Intermittent Both 3 23
F�rennial (�) or interrrittent Average (feet) (linear feet)
(If�
Intermittent Both
F�rennial (�) or interrrittent
QfV�
Intermittent Both
F�rennial (�) or interrrittent
QfV�
Perennial Both
F�rennial (F$2) or interrrittent
(If�
Perennial Both
F2rennial (FS2) or interrrittent
(If�
Perennial Both
F�rennial (F$2) or interrrittent
(If�
"" All Perennial or Intermittent streams must be verified by DWR or delegated local government.
3i. Total jurisdictional ditch impact in square feet:
0
3i. Total permanent stream impacts:
193
3i. Total temporarystream impacts:
24
3i. Total stream and tributary impacts:
217
3j. Comments:
Site 1(S1, S2, S3) includes the culvert extension of a 38" culvert under Brookshire Boulevard to provide a turn
lane for "Access D" from Brookshire. Site 2(S4, S5, S6) includes the placement of a 30" culvert to convey flow
under "Access D." Both areas include associated outlet stabilization.
3 17
Average (feet) (linear feet)
3 6
Average (feet) (linear feet)
2 128
Average (feet) (linear feet)
2 25
Average (feet) (linear feet)
2 18
Average (feet) (linear feet)
4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of the U.S. then individually list
all open water impacts below.
5. Pond or Lake Construction
If pond or lake construction is proposed, then complete the chart below.
6. Buffer Impacts (for DWR)

If project will impact a protected riparian buffer, then complete the chart below. Individually list all buffer impacts below.
, E. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:*
Existing drainage patterns v�re maintained and 2:1 slopes were used where possible to minimize impacts to
streams. Streams along the western side of Brookshire Boulevard were avoided completely by tweaking the
grading and layout of the roadway design. Riprap is used at drainage outlets to dissipate energy, reduce erosion
and stabilize stream banks where pipe outlet velocities are high.
A Duke Energy transmission line runs parallel to Brookshire Boulevard on the east side of the project area. Duke
requires 4:1 slopes within their right-of-way in order for maintenance vehicles to access the transmission line
corridor. (email correspondence with Duke Energy regarding requirements is attached). Side slopes of the access
road through Duke Energy's right of way were set at a 4:1 slope but quickly transitions to a 2:1 slope outside of
their right of way to minimize impacts to the stream.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:*
Typical sediment and erosion control measures will be taken on site. Silt fences and temporary sediment basins
will be utilized to prevent sediment from entering streams and wetlands.
' 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?
�' Yes l" No
2c. If yes, mitigation is required by (check all that apply):
r7 DWR rJ Corps
2d. If yes, which mitigation option(s) will be used for this project?
r Mitigation bank r% Payment to in-lieu fee program r Permittee Responsible Mitigation
4. Complete if Making a Payment to In-lieu Fee Program
4a. Approval letter from in-lieu fee program is attached.
r% Yes
4b. Stream mitigation requested:
(linear feet)
193
4c. If using stream mitigation, what is the stream temperature:
warm
4d. Buffer mitigation requested (DWR only):
(square feet)
n/a
4e. Riparian wetland mitigation requested:
(acres)
n/a
4f. Non-riparian wetland mitigation requested:
(acres)
n/a
4g. Coastal (tidal) wetland mitigation requested:
(acres)
n/a

4h. Comments
n/a
6. Buffer mitigation (State Regulated Riparian Buffer Rules) - required by DWR
6a. Will the project result in an impact within a protected riparian buffer that requires buffer mitigation? If yes, you must fill out this entire
form - please contact DWR for more information.
C' Yes �' No
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation
calculate the amount of mitigation required in the table below.
6c. Reason for impact
Zone 1 n/a
Zone 2 n/a
6d. Total impact Multiplier 6e. Required
(square feet) mitigation (square
fe e t)
6f. Total buffer mitigation required
n/a
6g. If buffer mitigation is required, is payment to a mitigation bank or NC Division of Mitigation Services proposed?
C' Yes C' No
6h. Attach the acceptance letter from the mitigation bank or NC Division of Mitigation Services.
(FDF only)
6i. If no, then discuss what type of mitigation is proposed.
n/a
6j. Comments:
n/a
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
1a. Does this project require a Stormwater Management Plan?
�' Yes C' No
1b. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
See attached permit drawings for NCDOT Stormwater management Plan. U-6084 (Riverbend) is a widening project
at the intersection of Brookshire Blvd (NC 16) and Mount Holly Huntersville Rd in Charlotte. Measures to reduce
impacts to streams, wetlands and surrounding properties include, maintaining exsting drainge patterns and using
2:1 fill slopes. Further, rip rap is used at drainage outlets to dissipate energy, reduce erosion and stabilize stream
banks where pipe outlet velocities are high.
1c. What is the overall percent imperviousness of this project?
36
%
1d. Who will be responsible for the review of the Stormwater Management Plan?*
r Certified Local Government r DEMLR Stormwater Review
r DWR 401 & Buffer Permitting Branch �7 DWR Transportation Permitting Branch
2. Diffuse Flow Plan

2a. Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian Buffer Protection
Rules?
f Yes C•' No
If no, explain why:
Even though project is within the Catawba River Basin, no protected buffer areas occur within the project area. Stormwater management
plan can be found in previously uploaded plan sheets.
5. DWR 401 Stormwater Review
5a. Is the Stormwater Management Plan (including BMP Supplemental Forms and Operation and Maintenance Agreements) attached?
C' Yes c' No
Stormwater Management Plan Upload
C7ick the upload button or drag and drop files here to attach docurrent
file type rrust be pdf
G. Supplementary Information
� 1. Environmental Documentation
1a. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state) land?*
r Yes C' No
1b. If you answered "yes" to the above, does the project require preparation of an environmental document pursuant to the
requirements of the National or State (North Carolina) Environmental PolicyAct (NEPA/SEPA)?*
�' Yes �' No
1c. If you answered "yes" to the above, has the document review been finalized by the State Clearing House? (If so, attach a copy of the
i NEPAor SEPAfinal approval letter.)*
C' Yes C•' No
Comments:*
A Minimum Criteria Determination Checklist has been completed for the project.
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)? *
C' Yes �' No
2b. Is this an after-the-fact permit application?*
C' Yes C•' No
2c. If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
n/a
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?*
C' Yes �' No
3b. If you answered "no," provide a short narrative description.
The proposed roadway improvements are being designed to handle existing traffic and added traffic pressures
e�ected from adjacent development to be completed in the next few years. It is not expected that this project will
result in additional development.

4. Sewage Disposal (DWR Requirement)
4a. 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.
No wastewater will be generated as part of this project.
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?*
C' Yes C•' No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
C' Yes C•' No
5d. Is another Federal agency involved?*
C' Yes C� No
5e. Is this a DOT project located within Division's 1-8?*
C' Yes C•' No
5f. Will you cut anytrees in order to conduct the work in waters of the U.S.?*
C' Yes C' No
5g. Does this project involve bridge maintenance or removal?*
C' Yes �' No
�' Unknown
Link to the NLEB SLOPES document: http://sav�reg.usace.arrny.mil/NLEB/1-30-17-signed_NLEB-SLOPES&apps.pdf
5h. Does this project involve the construction/installation of a wind turbine(s)?"*
C' Yes C' No
Si. 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.?*
C' Yes C' No
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?*
NHP Natural Heritage Data E�lorer and site evaluation
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
C' Yes C•' No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
NOAA Essential Fish Habitat Mapper (http://w�nnv.habitat.noaa.gov/protection/efh/efhmapper/index.html)
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
Link to 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)? *
C' Yes �' No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources? *
North Carolina State Historic Preservation Office HPOWEB GIS Service (http://gis.ncdcr.gov/hpoweb/)
7c. Historic or Prehistoric Information Upload

C7ick the upload button or drag and drop files here to attach docurrent
17-10-0028_NoSurvey.pdf 5.09MB
NC 16-SR 2004 (Mecklenburg) No Survey form.pdf 958.36KB
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8. Flood Zone Designation (Corps Requirement)
Link to the FEMA Floodplain Maps: https://msc.fema.gov/portal/search
8a. Will this project occur in a FEMA-designated 100-year floodplain?*
C' Yes �' No
8b. If yes, explain how project meets FEMA requirements:
n/a
8c. What source(s) did you use to make the floodplain determination?*
NC Floodplain Mapping - Flood Risk Information System (http://fris.nc.gov/fris/Home.asp�ST=NC)
Miscellaneous attachments not previously requested.
C7ick the upload button or drag and drop files here to attach docurrent
U-6084 MCDC.pdf 1000.09KB
U-6084_dukerow email.pdf 85.83K6
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Signature
*
fJ By checking the box and signing below, I certify that:
■ I have given true, accurate, and complete information on this form;
■ I agree that submission of this PCN form is a"transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic
Transactions AcY');
■ I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic
Transactions AcY');
■ 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:*
� Larry Thompson
Signature
r�F6 ��� �/.�f9r�c14h!
Date :
current_date
Initial Review
Is this project a public transportation project? *(')
G Yes C' No
Change only if needed.
i Has this project met the requirements for acceptance in to the review process?*
�' Yes
C' No

BIMS # Assigned*
i 20171506
Version#*
Reviewing Office *
Mooresville Regional Office - [phone]
Select Project Reviewer*
� Donna Hood:eads\drhood