20180365 Ver 1_Initial Review Form_20180314

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 3/9/2018 8:07:52 AM (Supplemental Submital)
Accept by Carpenter,Kristi 3/14/2018 11:40:21 AM (DOT project)
• The task was assigned to Carpenter,Kristi 3/9/2018 8:07 AM

Water Resources
ENVIRONMENTAL OUALITY
Staff Review:
ID#* Version *
20180365 1
Reviewer List:* Garcy Ward:eads\gpward
Select Reviewing Office:* Washington Regional Office -[phone]
Submittal Type:* 401 Application
Is the project located within a NC DCM Area of Environmental Concern (AEC)?*
l' Yes �' No r Unknown
Does this project �' Yes
require a request (' No
for payment to be
sent?*
Project Submittal Interim Form
subrritted: 3/9/2018
Submittal Type: �' New Project
C' Pre-Application Submittal
C' More Information Response
Project Contact Information:
Name: Paul Williams
Who is subrritting the irrforrretion?
Email Address: [e-mail]
Project Information:
Project Name: Courtesy Notification - Pasquotank SR 1117
Lula Meads Road - Pipe Replacement
Is this a public transportation project?*
C' Yes
l' No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?*
l' Yes �' No C•' Unknown
TI P#:
WBS#: 1.207011
(Applies to DOT projects only)

County(ies)*
Pasquotank
Describe the attachments:
This is a courtesy notification that NCDOT will be replacing a pipe in a jurisdictional area in Pasquotank
County under Nationwide Permit 3 conditions. Location is on a UT to Dam Creek, Stream Index No. 30-4-2,
Pasquotank River Basin.
Existing (2) 24"X45' RCP's will be replaced by (2) 24"X45' CAP's at N 36.156182° W 76.197483°.
Please upload all files that need to be submited.
Topo SR 1117 Lula Meads Road RMIP 2017-2018 - Pasquotank.pdf 957.17KB
Only pdF or Ivre files are accepted.
rJ By checking the box and signing box below, I certify that:
o I have given true, accurate, and complete information on this form;
o I agree that submission of this form is a"transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the
"Uniform Electronic Transactions AcY')
o 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');
o I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the form.
Signature:
.?f!r�rf! f✓frir..'%l'ffrrrrr�.rsf.