20200859 Ver 1_Certification of Completion_20230321 (2)

CERTIFICATE OF COMPLETION
NCDWR Project No.:
Applicant:
Project Name:
Date of Issuance of 401 Water Quality Certification:
County:
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 Wetland & Buffer 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: Z1�4 Date:
Agent's C ification
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:
Engineer's Certification
Partial Final
Date:
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