20180007 Ver 2_I-3804 permit completion forms_20201125

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ROY COOPER
Governor
MICHAEL S.REGAN
Secretory
Environmental LINDA CULPEPPER
Quality /�f 1 Interior Director
NCDWR Project No.: 2-0 8"0003- County:O�4N
Applicant: itiQ
Project Name: f Ve t)T n�erc�r� '� D-A
Date of Issuance of 401 Water Quality Certification: 1— - 5 )--0(
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.
Appllc n!'s Cerll cation
, hereby state that,to the best of my abilities, due care and diligence
was use in the servation f the construction such that the construction was observed to be built within substantial
compliance and tent of the 401 Water Quality Certification and Buffer Rules,the approved plans and
specifications, d other s►pporting materials. f f l ,,1
Signature: - -j�\f� ___.. Date:1L1 )-5/d-6�
Agent's Cerlificalioi { III
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
1, ,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
State of North Carolina I Environmental Quality
1617 Mail Service Center I Raleigh,North Carolina 27699-1617

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Action ID Number: SAW 2016-02124 County: Davidson
Permittee: NCDOT,Division 9,Attn: Amy Euliss Click here to enter text.
Project Name: I-3804
Date Verification Issued: 2/5/2018
Project Manager: Monte Matthews
Upon completion of the activity authorized by this permit and any mitigation required by the permit,
sign this certification and return it to the following address:
US ARMY CORPS OF ENGINEERS
WILMINGTON DISTRICT
Attn: Monte Matthews
Raleigh Regulatory Office
U.S Army Corps of Engineers
3331 Heirtage Tade Drive,Suite 105
Wake Forest,North Carolina 27587
Please note that your permitted activity is subject to a compliance inspection by a U.S.Army Corps of
Engineers representative. Failure to comply with any terms or conditions of this authorization may
result in the Corps suspending,modifying or revoking the authorization and/or issuing a Class I
administrative penalty, or initiating other appropriate legal action.
I hereby certify that the work authorized by the above referenced permit has been completed in
accordance with the terms and condition of the said permit, and required mitigation was completed in
accordance with the permit conditions.
Suture o error ec ate