20191387 Ver 1_Certification of Completion attachments_20200727

DocuSign Envelope ID: 55C62C8F-2607-4D07-A832-A30A9D2290C4

ROY COOPER
Governor MICHAEL S. REGAN
Secretary LINDA CULPEPPER

NORTH CAROLI NA En�lrmtm:tnto! Quallty
Director NCDWR Project No.: 20191387 County: Alexander

Applicant: NCDOT

Project Name: Bridge 120 on SR 1121

Date oflssuance of401 Water Quality Certification:

Certificate ofCompletion
November 7, 2019
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, Mark Stafford , 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: Mark Stafford Date: 7/27/2020
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.
Signature: 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 Registration No. _
Date

North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street I 1617 Mail Service Center I Raleigh, North Carolina 27699-1617
919.707.9000