20150057 Ver 1_DWR project completion form Br no 11_20150723

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NCDENR
North Carolina Department of Environment and Natural Resources
Pal McCrory
Governor
NCDWR Projec[ No.: � �1Q:i
Applicant: �iM� EL.1�' N'
Donald van der Vaart
Secretary
County: __.�0.V � �'�SDi�
Project Name: ��l L�y � ICCP� �lCeMell� U(,rois 5061�h 1 a}� �rQe �: li ✓� S(t �+�j 5
Dateoflssuanceof401 WaterQualityCertification: Fe�{"tAQ,(y +�'. ��� � _. __
Cer[iPcate 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 retum this certificate to the 401 Transportation Pennitting
Unit, North Carolina Division of Water Resources, 1G50 Mail Service Center, Raleigh, NC, 27699-1650. This fonn
may be returned to NCDWR by Ihe applicant, [he applicant's authori2ed agen[, or [he project engineer. It is not
necessary to send certificares from all of Uiese.
Appli nPs Cerliftcnlion
I, �iL �v" ( � S , hereby statc that, [o the best of my abilities, due care and di ligence
was used in th observation of 8ie construction such thai the construction was observed �o be built wi[hin substantial
compliance and intent of the 401 Water Quality Certification and BufFer Rules, the approved plans and
specifications, an oUter supporting materials. ���
Signature: _ , Date: _ ��" (
AgenYs Cerfiftention
�, , hereby state [hat, [o tlie best of my abilities, due care and diligence
was used in the obscrvation of the construction such that the construction was observed to be built within substantial
compliance and intent of tlie 401 Water Quality Ccrtification and Buffer Rules, the approved plans and
specifications, and other supporting materials.
Signahire:
Eegriieer's Cerliftcn/ion
Partial Final
Date:
1, , as a duly regis[ered Professional Engineer in the S[ate of NoKh
Cazolina, having been aud�orized to observe (periodically, weekly, full time) the construction of the project fa• the
Pennittee hereby state ihat, [o the bes[ oFmy 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 Certifica[ion and Buffer Rules, tlte approved plans and specifications, and other supporting materials.
Signature
Date
Registration No. _....
1617 Mail Service Center, Raleigh, Norih Carolina 27699-1617
Phone: 919�07-630011nIemeC www.ncdenr.gov
M Equal Oppotlunity 1 Affrmalive Action Employer