20191468 Ver 1_Certification of Completion_20211029

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit
BIMS Updated
by Anonymous User 10/29/2021 10:33:25 AM (Start)
by Carpenter, Kristi Lynn 10/29/2021 3:01:06 PM (DOT Project)
• The task was assigned to Carpenter, Kristi Lynn 10/29/2021 10:33 AM

Staff Review
.............................................................................................
DWR Project #: * 20191468
Reviewer List*
Version: *
Hannah Sprinkle:eads\hhsprinkle
1
CERTIFICATION SUBMITTED ON 10/29/2021
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?
USACE Permit# N/A
DWR Project #: 20191468
County: Fender
401 Water Quality Certification Issued Date:
Yes
No
Version: 1
11/1/2019
Applicant: NCDOT - Division 3
Project Name: NCDOT - SR 1504 Murray Town Road Burial Waiver
Supplemental Attachments: Click the upload button or drag and drop files here to attach document
SR 1504 DWR 401 Completion Form
Signed.pdf
PDF only
Who will be submitting the Certification of Completion?
Applicant
Agent
Certified Professional
Agent's Certification
1.17MB
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.
By checking the box and signing box below, I certify that:
0 I have given true, accurate, and complete information on this form;

a 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")
a I 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: Christopher Dustin
Signature

!WC
Water Resources
ENVIRONMENTAL QUALITY
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
NCDWR Project No.: 20191468 County: Pender
Applicant: NCDOT - Division 3
Project Name: NCDOT - SR 1504 Murray Town Road Burial Waiver
Date of Issuance of 401 Water Quality Certification: 11/01/2019
secretary
S. JAY ZIMMERMAN
lhrecror
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: Date:
Agent's Certification
I, Christopher Dustin , 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.
Christopher Dustin Date: ly signe.2 1 Christopher Dustin
Signature: Date: 2021.10.291031:45-04'00' Date: 10/29/2021
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
Permiee 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 (Environmental Quality I Water Resources
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Phone: [phone]