North Carolina Department of Environment and Natural Resources
Division of Water Resources

Forms and Checklists

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All documents may be downloaded in Portable Document Format (PDF), which can be viewed using Adobe Acrobat Reader.  Documents generated by the Public Water Supply Section 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 Public Water Supply Section at (919) 707-9053.

Application
Document
Description / Pages / Version

Application (MSWord)  (PDF)

NC Water/Wastewater Common Application
5 pages / September 2010

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 Documents

1 page
  • Bonus Points Scoring Checklist

2 pages
  • Resolution by Governing Body of Applicant (Sample)

Resolution by governing body of applicant agreeing to the terms of the prospective
loan or grant
1 page
  • Certification by Recording Officer

Certification of governing body resolution
by a recording officer
1 page
  • Request for Categorical Exclusion from Substantive Environmental Review

2 pages
  • Water & Sewer Utilities Revenue Form

2 pages
  • LGC-108A

Selected Fiscal Information as Certified by Financial Officer
2 pages
  • LGC-108C

Projection of Water and Sewer Net Revenues
2 pages
  • Checklist for Rate Structures that Support Water Conservation

Pursuant to the requirements of 
NCGS § 143-355.4.(b)(1).
3 pages
  • Checklist for Water Loss Reduction Program

1 page
  • Reclaimed Water Certification

Pursuant 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 Form
3 pages / May 25, 2011
Construction Bid / Contract and Compliance Documents
Document
Description / 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 Report
2 pages / (N/A)

DOL Form WH-1321 (English / Spanish PDF)

U.S. Dept. of Labor “Employee Rights Under the Davis-Bacon Act” Poster
1 page / (N/A)

EPA Form 4700-4 (PDF)

EPA Preaward Compliance Review Report for All Applicants and Recipients Requesting EPA Financial Assistance
2 pages / (N/A)

GSA Form SF-1445 (PDF)

U.S. General Services Administration Labor Standards Interview
1 page / (N/A)
Budget Approval
Document
Description / Pages / Version

Part B Form 1951B (MSWord) (PDF)

Offer and Acceptance of Loan or Grant for Water Supply System Project, Part B
10 pages / 30 March 2012
  • Engineer's Certification of Compliance with NCGS § 133-3

Certification that a specific product was not endorsed as part the project plans and specifications
1 page
  • Site Certificate by Title Counsel

1 page
  • Clear Site Certification

1 page
Reimbursement and Repayment
Document
Description / Pages / Version

Reimbursement Form

Link to Division of Water Quality's Funding Assistance Program website

Repayment Schedule Example (MSExcel) (PDF)

Example repayment schedule provided by the Local Government Commission
1 page / (N/A)

 
 

Public Water Supply Section, 1634 Mail Service Center, Raleigh, NC 27699-1634      919-707-9100      Fax  919-715-4374     Disclaimer | Contact Webmaster