NC DWR Completion Forms 2021

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ROY COOPER
Governor NORTH CAROLINA
MICHAEL S.REGAN Environmental Quality
Secretary
LINDA CULPEPPER U(2O Director NCDWR Project/No.:: County: �Q son
Applicant: !%VG !/ (/T Ayiii,00 0 [f
Project Name: �060 3I GSl'�{�tslctv� �o OL >Tq
Date of Issuance of 401 Water Quality Certification: 2
/2617
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 NCD WR 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 Certii lcadon
1, PO G ev- �rt/A N hereby state that,to the best of my abilities,due care and diligence
'was used the observation 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: 4 12 2 2
Agent's Certificat on
1, 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 ofthe 401 Water Quality Certification and Buffer Rules,the approved plans and
specifications,and other supporting materials.
Signature: Date:
Engineer's CertiJlcadon
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
Permittee 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
i��D ��ft North Carolina Department of Environmental Quality Division of Water Resources
512 North Salisbury Street 11617 Mail Service Center I Raleigh,North Carolina 27699-1617
'�" 919.707.9000