10. proposed work involves(check all that apply)

installation of new facility

Revision to existing facility*

Upgrade to existing facillity*

Existing agreement for the installation

yes

No

Unknown

11. Location of Installation:

Title:

Street Address:

city :

State :

zip :

Email :

Telephone Number :

Ext :

12.Railroad Milepost Reference* :

MP

+

Feet

*use the next lowest whole Milepost adjacent to the project location +feet inthe direction of increasing milepost tothe project location .Applies to all milepost references in the application.

Mainline -increasing milepost from Greensboro (MP 284) to Charlotte(MP 375)

H-line - increasing milepost from Greensboro (MP H-0) TO Goldboro(MP H-130)

EC-line -incresing milepost from Goldsboro(MP EC-0) to Morehead City (MP EC-94)

13.Orientation of pipeline Installation :

Transeverse Crossing only-fill in #14 below

Longitudinal (parallel to track) only -fill in #15below

Longitudinal and Transeversing crossing-fill in #16 below

14. For a Transeverse crossing under the tracks :

Number of tracks to be crossed:

Angle of crossing:

Total Length of the crossing on the NCRR Corridor :

Feet

15. For a longitudinally occupany only :

Begin at the Railroad milepost :

MP

+

Feet

End at the Railroad milepost :

MP

+

Feet

Total length of the crossing NCRR Corridor :

Feet

MIN. distance from centerline of nearest track of longitudinal portion :

Feet

16.For a longitudinal and transverse crossing :

Begin at Railroad milepost:

MP

+

Feet

End at Railroad milepost:

MP

+

Feet

Length Parallel:

Feet

Length Crossing:

Feet

MIN distance from the centerline of nearest track of longitudinal portion:

Feet

17. Will pipe line be located entirely within the confines of a public street?

yes

no

18. Will the installation connect to an existing facility within the NCRR Corridor?

yes

no

if yes,identify owner:

19. Method of proposed installation:

Bore and Jack

jacking

Tunneling (tunner liner plate)

Direction Boring/horizontal direction drilling

open cut

Other (please specify)

20. Are there any wires ,poles or obstruction to be relocated

yes

No

if yes,type of facility

Owner

To be relocated by

21. Will temporary track support or rip rapping be required?

yes

No

if yes,Provide details

22. Shut off valves?

yes

No

if yes,Location

23. Vents?

yes

No

if yes,Location

Number

size

Height above ground

24. Seals?

yes

No

if yes,both ends

one end

25. Any existing facilities to be abandoned or removed:

yes

No

if yes,explain

26.Character of subsurface materials:

27. Approximate ground water level:

28.Source of Information:

29. proposed construction

Start Date

Duration

Name of contractor

Define any special specifications of installation:

under ground facility

30. Total buried length on the NCRR Corridor :

Feet

31.Bury Depth:

From base of rail to top of casing

Feet

Minimum Depth on the NCRR Corridor but not beneath tracks:

Feet

Below ditches:

Feet

Aerials Facilities

32. Total aerial length on the NCRR Corridor :

Feet

33.Number of pole lines crossed :

34. Types of pipe supports :

35. Minimum height of pipe and support above top of rail:

Feet

36. Minimum height of pipe above wirelines:

Feet

37. Horizontal distance of pipe supports from centerlines of nearest track:

Feet

pipe data

38.Material to be conveyed:

Flameable:

yes

No

Temprature:

39.Maximum working pressure:

psi

Field test pressure:

psi

Type of Test:

40.Pipe data (Still Include Form NCR 102 Plate):

CARRIER PIPE

CASING PIPE

Material

Process of Manufacture

Material Specification

Material Grade

Minimum yield strength(psi) of material

Mill Test Pressure

Nominal Diameter

Inside diameter

Outside diameter

Weight per Foot

Wall Thickness

Type of seam

Laying Length

Type of joint

Type of Coatings

Cathodic Protection Detail

Protective Coating Details