20181149 Ver 1_Certification of Completion_20200122

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/22/2020 4:01:41 PM (Start)
BIMSUpdated by Carpenter, Kristi 1/22/2020 4:17:40 PM (DOT Project)
• The task was assigned to Carpenter, Kristi 1/22/2020 4:01 PM

Staff Review
DWR Project #:* 20181149 Version:* 1
Reviewer List* Joanne Steen h u is:eads\jhsteen h u is
CERTIFICATION SUBMITTED ON 1/22/2020
Upon completion of all work approved within the 401 Water Quality Certification or applicable Buffer Rules, and any
subsequent modifications, the applicant is required to submit it to the DWR 401 & Buffer Permitting Branch. This form
may be returned to DWR by the applicant, the applicant's authorized agent, or the project engineer. It is not necessary
to send certificates from all of these.
Is this a Public Transportation Project? rJ Yes
r No
USACE Permit# SAW-2018-01660
DWR Project M 20181149 Version: 1
County: Sampson
401 Water Quality Certification Issued Date:
8/21 /2018
Applicant: NCDOT Division 3
Project Name: Sampson County Sr 1004 Union School Road
Supplemental Attachments: Click the upload button or drag and drop fileshere toattach docurrent
SR 1004_401 Completion
1.19MB
Form.signed.pdf
SR 1004_404 Completion
80.77KB
Form.signed.pdf
FDF only
Who will be submitting the Certification of Completion?
r Applicant
r Agent
f Certified Professional
Agent's Certification
I, hereby state that, to the best of my abilities, due care and diligence was used in the observation of the construction
such that the construction was observed to be built within substantial compliance and intent of the 401 Water Quality
Certification and Buffer Rules, the approved plans and specifications, and other supporting materials.
fJ 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 the "Certificate of Completion" form is a "transaction" subject to Chapter 66, Article 40 of the
NC General Statutes (the "Uniform Electronic Transactions Act')
0 1 agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act');
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 "Certificate of Completion" form."
Printed Name: Sean Farrell
Signature

•
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
" Secretary
Water Resources S. JAY ZIMMERMAN
ENVIRONMENTAL QUALITY
Director
NCDWR Project No.: 20181149 County: Sampson
Applicant: NCDOT - Division 3
Project Name: NCDOT - Pipe Replacement on SR 1004
Date of Issuance of 401 Water Quality Certification: 08/21/2018
Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification or applicable Buffer Rules,and
any subsequent modifications,the applicant is required to return this certificate to the 401 Transportation Permitting
Unit,North Carolina Division of Water Resources, 1617 Mail Service Center,Raleigh,NC,27699-1617. This form
may be returned to NCDWR by the applicant,the applicant's authorized agent,or the project engineer. It is not
necessary to send certificates from all of these.
Applicant's Certification
I, ,hereby state that,to the best of my abilities,due care and diligence
was used in the observation of the construction such that the construction was observed to be built within substantial
compliance and intent of the 401 Water Quality Certification and Buffer Rules,the approved plans and
specifications,and other supporting materials.
Signature: Date:
Agent's Certification
I, Sean Farrell ,hereby state that,to the best of my abilities,due care and diligence
was used in the observation of the construction such that the construction was observed to be built within substantial
compliance and intent of the 401 Water Quality Certification and Buffer Rules,the approved plans and
specifications,and other supporting materials.
Digitally signed by Sean Farrell Q 1/22/2020
Signature: Date:2020.01.22 15:58:34-05'00' Date:
Engineer's Certification
Partial Final
I, ,as a duly registered Professional Engineer in the State of North
Carolina,having been authorized to observe(periodically,weekly,full time)the construction of the project for the
Permiee hereby state that,to the best of my abilities,due care and diligence was used in the observation of the
construction such that the construction was observed to be built within substantial compliance and intent of the 401
Water Quality Certification and Buffer Rules,the approved plans and specifications,and other supporting materials.
Signature Registration No.
Date
State of North Carolina'Environmental Quality I Water Resources
1617 Mail Service Center,Raleigh,North Carolina 27699-1617
Phone:[phone]

Action ID Number: County:

Permittee:

Project Name:

Date Verification Issued:

Project Manager:

Upon completion of the activity authorized by this permit and any mitigation required by
the permit, sign this certification and return it to the following address:

US ARMY CORPS OF ENGINEERS
WILMINGTON DISTRICT
Attn:
_FIELD_OFFICE_

Please note that your permitted activity is subject to a compliance inspection by a U. S.
Army Corps of Engineers representative. Failure to comply with any terms or conditions
of this authorization may result in the Corps suspending, modifying or revoking the
authorization and/or issuing a Class I administrative penalty, or initiating other
appropriate legal action.

I hereby certify that the work authorized by the above referenced permit has been
completed in accordance with the terms and condition of the said permit, and required
mitigation was completed in accordance with the permit conditions.

_______________________________________ ______________________
Signature of Permittee Date