20220002 Ver 1_Certification of Completion_20220421

Staff Review
.............................................................................................
DWR Project #: * 20220002
Reviewer List*
Version: *
Doug Perez:eads\djperez
CERTIFICATION SUBMITTED ON 4/21/2022
1
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?
USACE Permit#
DWR Project #: 220002
County: Lincoln
401 Water Quality Certification Issued Date:
Applicant: Richard Balsley ii
Yes
' No
Version: 1
Project Name: Shoreline remediation lot 26 governors island
Supplemental Attachments: Click the upload button or drag and drop files here to attach document
PDF only
Who will be submitting the Certification of Completion?
Applicant
Agent
Certified Professional
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.
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")

o I 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: Richard Balsley ii
Signature