20191164 Ver 1_Certification of Completion_20200402

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/2/2020 11:21:16 AM (Start)
BIMSUpdated by Carpenter, Kristi 4/2/2020 1:34:58 PM (DOT Project)
• The task was assigned to Carpenter, Kristi 4/2/2020 11:21 AM

Staff Review
DWR Project #:* 20191164 Version:* 1
Reviewer List* Joanne Steen h u is:eads\jhsteen h u is
CERTIFICATION SUBMITTED ON 4/2/2020
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? V Yes
r- No
USACE Permit# SAW-2019-01653
DWR Project M 20191164 Version: 1
County: Sampson
401 Water Quality Certification Issued Date:
9/3/2019
Applicant: NCDOT - Division 3
Project Name: SR 1116 Pearson Road maintenance excavation
Supplemental Attachments: aickthe upload button ordrag and drop fileshere toattach docurrent
SR1116_401—Completion Form. pdf 656.67KB
SR1116_404_CompletionForm. pdf 122.36KB
FDF only
Who will be submitting the Certification of Completion?
f Applicant
r Agent
f Certified Professional
Agent'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.
W 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)
0 1 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: Sean Farrell
Signature