20171338 Ver 1_401 completion form_20200930

PAT MCCRORY
(rn e.nor
DONALD R. VAN DER VAART
Sccrctar!.
Environmental JAY ZIMMERMAN
Quality DV+R Direct(r
NCDWR Project No.: 20171338 County: Forsyth
Applicant: North Carolina Department of Transportation Division 9
Project Name: Bridge 95 on SR 1100 Lasater Road B-5152
Date of Issuance of 401 Water Quality Certification: November 6, 2017
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
1, Stephanie Braquet ,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,a other sup orting materials.
Signature: Date: September 30, 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
• 'Nothine Cannp4rc's
State of North Carolina:Environmental Quality
1611 Mail Service Center 1 Raleigh.North Carolina 2 7699-1 6 1 1
919-707-9000