20130833 Ver 1_Certification of Completion_20141015

Action ID Number:SAW 2013 01423
Permittee: NC DOT, attn: Greaorv J. Thorue / Jason Dildav TIP B-4740
Date VeriTcation Issued: Aueust 6, 2013
Project Manager: John Thomas
County:Davidson
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
Raleigh REGULATORY FIELD OFFICE
3331 Heritage Trade 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. If you fail to comply with this permit you are subject to permit suspension,
modiScation, or revocation.
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.
� � � - ���
at e of Permittee
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Date

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I�CDE�IR
North Carolina Department of Environment and Natural
Division of Water Resources
Water Quality Programs
Pat McCrory Thomas A. Reeder John E. Skvarla, III
Govemor Director Secretary
NCDWR Project No.: !'�`�' ` ��� 3 County: �.� S� %1
Appticank /vv� \ � ���
Resources
Project Name: � i �
Date of Issuance of 401 Water Quality Certification: (� "�^�� ��
Certificate of Completion
Upon complerion of all work approved witlrin the 401 Water Quality Cer[ificafion or applicable Buffer Rules, and
any subsequent modifications, the applicant is required to retum this certificate to the 401 Transportation Pemiltting
Unit, North Carolina Division of Water Resources, 1650 Mail Service Center, Raleigly NC, 27699-1650. This forrn
may be returned to NCDWR by the applicant, the applicanYs authorized agent, or the project engineer. It is not
necessary to send certi£icates from all of these.
ApplicanNs Certificatian �
I, �c.� � U� S S"� `� ��� ��?. � hereby state that, to the best of my abilities, due care and diligence
was use ' the bservaHon of the construction such that the construction was observed to be built within substanflal
compliance and intent of the 401 Water Quality Certificarion and Buffer Rules, [he approved plans and
specifications, d other suppor ' mate� �� �!�
Signature: Date: /
AgenPs Certification
I, , hereby state that, to the best of my abilities, due care and diligence
was used in the observation of the construcrion such that the construction was observed to be built within substantial
compliance and intent of tl�e 401 Water Quality Certificafion and Buffer Rules, the approved plans and
specifications, and other supporting materials.
Signature:
Engineer's CeKificatron
Paztial Final
I, , as a duly registered Professional Engineer in the State of NortL
Carolina, haviug been authorized to observe (periodically, weekly, full rime) the conshuction of the project for the
Permittee hereby state [hat, to the best of my abiliries, due care and diligence was used in the observation of the
construcrion such that the consirucrion was observed to be built within substantial compliance and intent of the 401
Water Quality CertificaHon and Buffer Rules, the approved plans and specificarions, and other supporting materials.
Signahve
Date
Division ot Water Resources-Winston Selem Regional Office
locafion: 565 Waughlown St Winslon-Salem, North Carolina 27107
Phone: [phone] FAX: [phone] Customer Service: 1A77�6238748
Intemet www.navater.o�g
An Equal OpporNniry 1 Affirmative Action Employer
Regisltarion No.
�o e Carolina
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