20201544 Ver 1_Certification of Completion_20211029

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit
BIMS Updated
by Anonymous User 10/29/2021 10:20:07 AM (Start)
by Carpenter, Kristi Lynn 10/29/2021 3:01:20 PM (DOT Project)
• The task was assigned to Carpenter, Kristi Lynn 10/29/2021 10:20 AM

Staff Review
.............................................................................................
DWR Project #: * 20201544
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?
Yes
No
USACE Permit# SAW-2020-02096
DWR Project #: 20201544 Version: 1
County: Duplin
401 Water Quality Certification Issued Date:
12/9/2020
Applicant: NCDOT - Division 3
Project Name: NCDOT - SR 1975 Lighthouse Road Pipe Burial Waiver
Supplemental Attachments: Click the upload button or drag and drop files here to attach document
SR 1975 DWR 401 Completion Form
signed.pdf
SR 1975 USACE 404 Completion Form
signed.pdf
PDF only
Who will be submitting the Certification of Completion?
Applicant
Agent
Certified Professional
Agent's Certification
1.17MB
57.01KB
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:

a 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