20201553 Ver 1_CofC attachments_20211026

PAT MCCRORY
Governor
N
DONALD R. VAN DER VAART
" secretary
Water Resources S. JAY ZIMMERMAN
ENVIRONMENTAL QUALITY
lhrector
NCDWR Project No.: 20201553 County: Sampson
Applicant: NCDOT - Division 3
Project Name: NCDOT - SR 1845 Rosin Hill Road Pipe Burial Waiver
Date of Issuance of 401 Water Quality Certification: 12/04/2020
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
1, 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 �USt�ll Digitally signed by Christopher Dustin
Signature: Date:2021.10.2615:30:06-04'00' Date: 10/26/2021
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
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 lEnvironmental Quality I Water Resources
1617 Mail Service Center,Raleigh,North Carolina 27690,1617
Phone:[phone]