20171491 Ver 1_Certification of Completion_20230511

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/11/2023 8:29:12 AM (Start)
BIMS Updated by kristilynn.carpenter 5/16/2023 10:19:10 AM (DOT Project)
• The task was assigned to kristilynn.carpenter 5/11/2023 8:29:17 AM

Staff Review
DWR Project #: * 20171491 Version: * 1
Reviewer List* Dave Wanucha:eads\djwanucha
CERTIFICATION SUBMITTED ON 5/11/2023
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#
DWR Project #: 20171491 Version: 1
County: Gaston
401 Water Quality Certification Issued Date: 1/18/2018
Applicant: Mark Stafford, NCDOT
Project Name: NC 279 Widening, W-5212N
Supplemental Attachments: Click the upload button or drag and drop files here to attach document
PDF only
Who will be submitting the Certification of Completion?
Applicant
Agent
Certified Professional
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.
By checking the box and signing box below, I certify that:
o I have given true, accurate, and complete information on this form;
o 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")
o 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: M. Caleb BrabbleRose
Signature
M. Cale. ,y►'a.�hleRose