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N.C. Department of Environment and Natural Resources

NC Department of Environment and Natural Resources
Water Infrastructure - Forms and Checklists

Water Infrastructure

 

Forms and Checklists

All documents may be downloaded in Portable Document Format (PDF), which can be viewed using Adobe Acrobat Reader.  Documents generated by the Division of Water Infrastructure are also available for download in Microsoft Word or Microsoft Excel document format so that the Applicant may enter and save information necessary to complete the associated forms and checklists. Some of the following documents, such as the Application Appendix and the Part B, contain multiple forms. These documents are accompanied by an outline of the forms and checklists contained therein. If you have any problems downloading any of the following documents, contact the division at (919) 707-9160.

Application

DocumentDescription / Pages / Version
Application (MSWord)¿(PDF)
North Carolina Department of Environment & Natural Resources Application Appendix for Drinking Water Funding Programs(MSWord) (PDF)Appendix to the application including checklists, forms, and supplemental information for Drinking Water Loan and Grant Programs (High Unit Cost, Emergency Loans, and Drinking Water State Revolving Fund)36 pages / 22 July 2011
Checklist for Required Drinking Water Application Supporting Documents1 page
Bonus Points Scoring Checklist2 pages
Resolution by Governing Body of Applicant (Sample)Resolution by governing body ofapplicant agreeing to the terms of the prospective loan orgrant1 page
Certification by Recording OfficerCertification of governing bodyresolution by a recording officer1 page
Request for Categorical Exclusion from Substantive Environmental Review2 pages
Water & Sewer Utilities Revenue Form2 pages
LGC-108ASelected Fiscal Information asCertified by Financial Officer2 pages
LGC-108CProjection of Water and Sewer Net Revenues2 pages
Checklist for Rate Structures that Support Water ConservationPursuant to the requirements of NCGS 143-355.4.(b)(1).3 pages
Checklist for Water Loss Reduction Program1 page
Reclaimed Water CertificationPursuant to the requirements of NCGS 143-355.4.(b)(6).2 pages
Water & Sewer Utilities Revenue Form:  Future Rate Calculations Spreadsheet(MSExcel(PDF)Spreadsheet tool for calculation of projected average user fees and rates for the Water & Sewer Utilities Revenue Form3 pages / May 25, 2011

Construction Bid / Contract and Compliance Documents

DocumentDescription / Pages / Version
Disadvantaged Business Enterprise (DBE) Forms (Special Conditions Packages)Link to the DBE page
DOL Form WH-347 (PDF)U.S. Dept. of Labor Weekly Payroll Report2 pages / (N/A)
DOL Form WH-1321 (English / Spanish PDF)U.S. Dept. of Labor “Employee Rights Under the Davis-Bacon Act” Poster1 page / (N/A)
EPA Form 4700-4 (PDF)EPA Preaward Compliance Review Report for All Applicants and Recipients Requesting EPA Financial Assistance2 pages / (N/A)
GSA Form SF-1445U.S. General Services Administration Labor Standards Interview1 page / (N/A)

Budget Approval

DocumentDescription / Pages / Version
Part B Form 1951B (MSWord) (PDF)Offer and Acceptance of Loan or Grant for Water Supply System Project, Part B10 pages / 30 March 2012
Engineer's Certification of Compliance with NCGS 133-3Certification that a specific product was not endorsed as part the project plans and specifications1 page
Site Certificate by Title Counsel1 page
Clear Site Certification1 page

Reimbursement and Repayment

DocumentDescription / Pages / Version
Reimbursement FormLink to Division Clean Water Loan Program page
Repayment Schedule Example (MSExcel) (PDF)Example repayment schedule provided by the Local Government Commission1 page / (N/A)
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For assistance contact us at (919) 707-9160

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N.C. Division of Water Infrastructure

Mailing Address (USPS): 1633 Mail Service Center, Raleigh, North Carolina, 27699-1633

Street Address (FedEx, UPS): 512 N. Salisbury St, Raleigh, North Carolina, 27604

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