NCDWR completion form

DocuSign Envelope ID: 1FE1469B-6554-4A2C-A14E-BAD7F2AE3520
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
S. DANIEL SMITH
Director
NORTH CAROLINA
EnKronmentat Quality
NCDWR Projec
Applicant:
Project Name: �� 23D UVt $� 2ZSy Date of Issuance of 401 Water Quality Certification: 5+t 1MWP�1 9, Z 1) l
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, -4¢ p\rrah 1 G B lyvu ue t , hereby state that, to the best of my abilities, due care and diligence
was use in the observation of thb construction such that the construction was observed to be built within substantial
compliance an mte of the 4 Water Quality Certification and Buffer Rules, the approved plans and
specifications, %d o�er supNong matetjlals. , ,
Date: v 1 I C'el I 2-DZ3
Agent's
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:
Engineer's Certification
Partial Final
Date:
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
Date
Registration No.
D_EQ� North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 11617 Mail Service Center I Raleigh, North Carolina 27699-1617
m r
979.707.9000