NC DWR Completion Forms 2021 (2)

ROY COOPER
Governor
MICHAEL S. REGAN
.Secrelan'
Environmental
LINDA CULPEPPER
Quality Lnerim Director
NCDWR Project No.: ZO(80Lo/ County: �c.ncOwvLc
Applicant: /yG 1>0T
Project Name:
Date of Issuance of 401 Water Quality Certification: F-�
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, llli 4 c,,, m tc''t ,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: /2 Ap Z Z
Agent's Certification
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 of the 401 Water Quality Certification and Buffer Rules,the approved plans and
specifications,and other supporting materials.
Signature: Date:
Engineer's Certification
Partial Final
1, 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
State of North Carolina I Environmental Qualip
1617 Ylail Service Center I Raleigh,North Carohna 2 7699-1 6 1 7