20151265 Ver 1_Certification of Completion_20200508

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/8/2020 5:48:11 PM (Start)
BIMSUpdated by Carpenter, Kristi 5/11/2020 9:45:26 AM (DOT Project)
• The task was assigned to Carpenter, Kristi 5/8/2020 5:48 PM

Staff Review
DWR Project #:* 20151265 Version:* 1
Reviewer List* Joanne Steen h u is:eads\jhsteen h u is
CERTIFICATION SUBMITTED ON 5/8/2020
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
F- No
USACE Permit# SAW-2015-02592
DWR Project M 20151265 Version: 1
County: Brunswick
401 Water Quality Certification Issued Date:
12/14/2015
Applicant: NCDOT Division 3
Project Name: SS-4903BR Ocean Isle Beach Roundabout (SR1184)
Supplemental Attachments: aickthe upload button ordrag and drop fileshere toattach docurrent
SS-
1.17MB
4903BR completionform DWR_201512...
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: Anneliese Westphal
Signature

Water Resources
ENVIRONMENTAL QUALITY
NCDWR Project No.: 20151265
Applicant: NCDOT Division 3
Project Name:
County:
SS-4903BR OIB Roundabout (SR 1184)
Date of Issuance of 401 Water Quality Certification:
12/14/2015
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Brunswick
Secretary
S. JAY ZIMMERMAN
lhrector
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 Transportation 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:
Agent's Certification
Date:
1, Anneliese Westphal , 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.
Date:2020.05.08 17:29:42 5/8/2020
Signature:-04'00' Date:
Engineer's Certification
Partial Final
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
Date
Registration No.
State of North Carolina lEnvironmental Quality I Water Resources
1617 Mail Service Center, Raleigh, North Carolina 27690,1617