NCDOT Site Information Form

Site Information Form

North Carolina NEVI Program
- Applicants may complete MULTIPLE Site Information Forms for NCDOT NEVI RFP Round II.
- Applicants should complete all information.
- An "Applicant ID" is required in order to submit this form, and is provided after submission of the Team Information Form. However, an Applicant ID is not needed in order to enter data into this form and save progress.
- If you have any additional questions, please contact ncnevi@NCDOT.gov.
Note: You may save your progress using the "Save" button at the bottom of each page. You will be emailed a link to resume your application form later. We recommend saving your progress regularly to avoid losing input.
Applicant ID:*
Your unique Applicant ID is available with your Team Information submission record, which must be submitted first.
Applicant contact email address:*
example@example.com
1. Proposed Site Location Details
1.1 Distance to Alternative Fuel Corridor (AFC) and nearest interstate interchange (provide measurements with a resolution of 0.01 mile), as defined in Attachment 1, Technical Requirements:
R2-17-2R2-17-4R2-17-5R2-26-1R2-26-2R2-64-1R2-64-2R2-64-3R2-64-4R2-70-3R2-73-1R2-73-2R2-74-1R2-74-3R2-74-4R2-74-5
1.3 Interstate exit number or cross street:
Note: The coordinates below shall indicate the location of the driving point of entry (curb cut) to the charging station, as defined in 23 CFR 680.104
1.4 Latitude:
1.5 Longitude:
1.6 Provide the parcel number for the charging station:
1.7 Site name:
1.8 Physical address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1.9 Site host (entity) legal name and d/b/a:
1.10 Site utility provider:
2. EVSE Technical Requirements
2.1 Provide specification cut sheets for EVSE that clearly identifies the following information per port:
- Power
- Output current
- Output voltage
- Ambient operating temperature
- Enclosure environmental rating
Upload PDF, Word, Excel, or image file(s).
Cancelof
2.2 Provide a diagram of the proposed EV charging equipment and electrical connections including equipment power and/or energy ratings, as applicable. Include the utility transformer, charging cabinet(s), dispensers, connectors, batteries, solar panel(s), and any other proposed electrical equipment in the diagram, as applicable.

The diagram should clearly indicate any power sharing arrangement between ports such that the power available per port can be determined based on the number of ports in use. The definition of charger, charging port, and connector shall be as defined in 23 CFR 680.104.
Upload PDF, Word, Excel, or image file(s).
Cancelof
2.3(a) EVSE vendor (entity) name:
2.3(b) EVSE make and model:
2.3(c) Confirm proposed EVSE is Build America, Buy America compliant, per requirements.
YesNo
2.4(a) Confirm each 150 kW or higher direct current fast charging (DCFC) EVSE is capable of simultaneously providing at least 150kW per port (Applies to the four required ports; additional ports are addressed in Section 4.1).
YesNo
2.4(b) Confirm a minimum of 4 NACS connectors and 4 CCS1 connectors are provided, per requirements.
YesNo
YesNo
YesNo
2.5(c) What is the size of the battery per port in kWh?
2.5(d) What is the overall size of the battery in kWh?
2.5(e) What is the overall power output rating of the battery in kW?
YesNo
2.6 What is the planned station demand from the grid in kW or the planned size of the utility transformer in kVA?
2.7 Expected utility upgrades required:
3. General Project Approach and Understanding
3.1 Complete Attachment 5, Proposed Project Schedule, per the instructions provided within the attachment, and attach it to this application as a .xlsx file.
Upload Excel spreadsheet file(s).
Cancelof
4. EVSE and Utility Information
4.1 Number of 150 kW or greater DCFC ports:

4.2(a) Enter the maximum DCFC power in kW available for each car operating concurrently in these scenarios:

Rows	Vehicle 1 power	Vehicle 2 power	Vehicle 3 power	Vehicle 4 power
1 vehicle charging
2 vehicles charging
3 vehicles charging
4 vehicles charging

4.2(b) If the site contains more than four ports, explain the power sharing configuration, per the above.
Complete Attachment 12, Completed Utility Data Request Form (with rate schedule included), per the instructions provided within the attachment, and attach it to this application.
Cancelof
5. Approach to Site Requirements
5.1(a) Who is responsible for general site maintenance (trash removal, lighting, general site upkeep, etc.)?
5.1(b) What is the proposed frequency for general site maintenance (trash removal, lighting, general site upkeep, etc.)?
5.1(c) Who is responsible for general snow/ice removal?
5.1(d) What is your response time for snow and ice removal?
YesNo
YesNo
6. Proposed Site Details, Design, and Layout
6.1 Site Map (Preliminary site design and layout)
- Describe the approach to each item in section 6 listed below.
- Clearly identify each item within a preliminary site design and layout attached to this application.
- The preliminary site design and layout must be clear, legible, and drawn to scale.
- All items must be located on-site and under the control of the Applicant Team.
Upload PDF, Word, Excel, or image file(s).
Cancelof
6.2 What is the distance (in miles) from the entrance of the EVSE charging station to the AFC?
ExistingProposed/Modifications
6.3(b) Provide additional vehicular access detail:*
ExistingProposed/Modifications
6.4(b) Provide additional site improvements detail:*
ExistingProposed/Modifications
6.5(b) Provide additional EVSE charging spaces detail:*
ExistingProposed/Modifications
6.6(b) Provide additional ADA-compliant charging spaces detail:*
ExistingProposed/Modifications
6.7(b) Provide additional EV charge ports detail:*
Reference 23 CFR 680.104
ExistingProposed/Modifications
6.8(b) Provide additional electrical infrastructure detail:*
ExistingProposed/Modifications
6.9(b) Provide additional lighting detail:*
ExistingProposed/Modifications
6.10(b) Provide additional trash receptacles detail:*
ExistingProposed/Modifications
6.11(b) Provide additional wayfinding signage detail:*
ExistingProposed/Modifications
6.12(b) Provide additional EVSE charging station signage detail:*
ExistingProposed/Modifications
6.13(b) Provide additional physical protection detail:*
ExistingProposed/Modifications
6.14(b) Provide additional EVSE emergency shut off detail:*
YesNo
6.15(b) Provide details on proposed mitigations at the site to protect the equipment in the case of a flooding event:*
The FEMA Flood Map Service Center floodplain map can be found here. This map has a 100-year floodplain layer.
6.16 Any additional information on proposed site design and layout, including any additional amenities not already outlined?*
7. Area Map
7.1 Area Map
- Describe the approach to each item in section 7 below.
- Attach an area map that clearly identifies each required item.
- The area map must be clear, legible, and include a scale.
- Show the site location in relation to the State Highway/Interstate.
- Indicate the distance from the interchange to the site, as defined in the RFP.
Upload PDF, Word, Excel, or image file(s).
Cancelof
ExistingProposed/Modifications
7.2(b) Provide additional vehicular access from AFC detail:*
8. Primary Amenities
If included in the proposal, describe the approach to each item below and clearly identify each item in the preliminary site design and layout attached to this application.
- Amenities must be on site and controlled by Applicant Team.
ExistingProposedN/A
8.1(b) Restroom hours available each day:
8.1(c) Provide additional restroom detail (required if existing or proposed):
ExistingProposedN/A
8.2(b) Food and drink hours available each day:
8.2(c) Provide additional food and drink detail (required if existing or proposed):
ExistingProposedN/A
8.3(b) Retail/shopping hours available each day:
8.3(c) Provide additional retail/shopping detail (required if existing or proposed):
ExistingProposedN/A
8.4(b) Provide additional canopy detail (required if existing or proposed):
ExistingProposedN/A
8.5(b) Provide additional pull-through charger space detail (required if existing or proposed):
ExistingProposedN/A
8.6(b) Hours staff is on-site and available each day:
YesNo
8.6(d) Provide additional on-site staff detail (required if existing or proposed):
ExistingProposedN/A
8.7(b) Energy storage hours available each day:
8.7(c) Provide additional energy storage detail (required if existing or proposed):
ExistingProposedN/A
8.8(b) Provide additional future-proofing detail (required if existing or proposed):
Additional Attachments
Upload additional application Attachment files here.
- Attachment 6 – Signed Cost Proposal Form
- Attachment 7 – Signed Site Host Letter of Intent
- Attachment 9 – Acknowledgement of FHWA Form 1273
- Attachment 13 – Signed Certifications
Cancelof
9. Site Responsiveness Check

Applicants to indicate that the following application requirements are met:*

Rows	Yes	No
9.1 Application is submitted by the application deadline and in the format outlined by the RFP.
9.2 Application includes a completed letter from the site owner, as defined.
9.3 Application includes an organizational chart, as defined.
9.4 Application includes specification cut sheets for all proposed EV charging equipment.
9.5 Application includes a preliminary site design and layout, as defined.
9.6 Application includes an Area Map, as defined.
9.7 Application includes signed FHWA Form 1273.
9.8 Application includes acknowledgement of all issued addendums.
9.9 All sections of Attachments 3 and 4, Applicant Team and Site Information Form, are completed.
9.10 All sections of Attachment 5, Proposed Project Schedule, are completed.
9.11 All inputs required in Attachment 6, Cost Proposal Form, are provided.
9.12 Application includes Attachment 12, Utility Data Request Form.
9.13 Application includes the applicable utility rate schedule(s), including demand charge structure, attached to Attachment 12 (Utility Data Request Form).
9.14 Applicant does not appear on any list of suspended or debarred individuals or entities, as defined by the State of North Carolina.
9.15 Applicant is not barred or suspended from consideration for work with the federal government and does not appear on the Federal Excluded Parties List.
9.16 Applicant is registered to do business in the state of North Carolina and has provided Applicants Federal Tax ID Number within the application.
9.17 Applicant has provided Applicant’s unique entity identifier within the application.
9.18 At least 20 percent non-federal match is provided by other sources.

10. Technical Responsiveness Check

Applicants to indicate that the following site requirements are met:*

Rows	Yes	No
10.1 The EV charging site is within the required driving distance between the end of at least one off-ramp at the AFC interchange(s) and the entrance to the charging station, as defined in Table 4-1 of the RFP.
10.2 Site includes at least one ADA-compliant parking space with access to the EV charging infrastructure.
10.3 Charging is publicly available 24 hours a day, 365 days a year.

Applicants to indicate that the following EV charger requirements are met:*

Rows	Yes	No
10.4 EVSE supports at least 150 kW per port simultaneously across at least four ports for continuous charging and has minimum station power capability that meets the requirements in the RFP (the definitions of ports and connectors shall be the same as 23 CFR 680.104).
10.5 EVSE has minimum of four DCFC ports (the definition of ports shall be the same as 23 CFR 680.104).
10.6 EVSE has the capacity to deliver direct current (DC) output up to at least 350 amps (ADC).
10.7 EVSE is capable of operating at an ambient temperature range of minus 22 degrees to 122 degrees Fahrenheit.
10.8 EVSE enclosures have a minimum rating of IP54 or equivalent.
10.9 DCFC EVSE has the ability to provide DC output voltages somewhere within the range of 250–920 volts (VDC).
10.10 All DCFC EVSE includes combined charging system (CCS1) connectors capable of simultaneously DC fast charging all ports continuously, and all Level 2 EVSE has J1772 connectors capable of simultaneously charging all ports continuously.
10.11 Proposal includes assurances that Applicant will include North American Charging Standard (NACS) connectors for DCFC EVSE, per Attachment 1, Technical Requirements.
10.12 EVSE has been certified by an OSHA NRTL to the appropriate UL standards.
10.13 EVSE meet the Minimum Power Supply and Battery Energy Storage System Requirements per Attachment 1, Technical Requirements.

Applicants to indicate that the following miscellaneous requirements are met:*

Rows	Yes	No
10.14 EVSE site meets all requirements of the RFP and 23 CFR 680 as detailed in RFP.

Should be Empty:

Site Information Form

1. Proposed Site Location Details

2. EVSE Technical Requirements

3. General Project Approach and Understanding

4. EVSE and Utility Information

5. Approach to Site Requirements

6. Proposed Site Details, Design, and Layout

7. Area Map

8. Primary Amenities

Additional Attachments

9. Site Responsiveness Check

10. Technical Responsiveness Check