20120073 Ver 3_Certification of Completion_20180119

Action History (UTC-05:00) Eastern Time (US & Canada)
�brrrit by Anonymous User 1/19/2018 2:51:25 PM (Start)
BIMSUpdated by Carpenter,Kristi 1/22/2018 1:12:58 PM (DOT Project)
• The task was assigned to Carpenter,Kristi 1/19/2018 2:51 PM

Water Resources
� � � � � ENVIRONMENTALOUALITY
Staff Review
DWR Project #: 20120073
Version: 3
Upon completion of all v�rork 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 applicanYs authorized agent, or the project engineer. It is not necessary
to send certificates from all of these.
Is this a Public Transportation Project? �J Yes
�� No
DWR Project #: Version:
20120073 3
County: Person
401 Water Quality Certification Issued Date:
12/10/2013
Applicant: NCDOT
Project Name: Widening of US 501 from NC 49 to
SR 1602 (Jesse Banks Road); TIP:
R-2241 A
Su pple me ntal AttaChme nts: C7ick the upload button or drag and drop files here to attach docurrent
F�F only
Who will be submitting the Certification of Completion?
C' Applicant
r Agent
f 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.
�I7 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 AcY')
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 AcY');
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: Chris Murray
Signature
�F�1.5 �(�1i��.¢Y