20121131 Ver 2_Certification of Completion_20151029

Action ID Number:SAW 2012 00292
Permittee: NC DOT, attn: Gre�orv J. Thorne / Jim Mason
Date Verification Issued: Februarv 4, 2013
Project Manager: John Thomas
Counly:Stokes
Upon completion of the activity authorized by this permit and any mitigation required by thc 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 2758 i
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,
modification, 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.
10-��-�s
Date

North Carolina
1�
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NCDEPI�
Department of Environment and
Division of Water Quality
Pa� McCrory Charles Wakild, P E.
Governor Director
NCDWQProjectNo.: .L�J �_ �I�
Applicant:
Natural Resources
County: � �c
John E Skvada, III
Secretary
ProjectName: V Y"(b —I.i ���f �VO�S ��f� �U �,� (/t`� `7L
Date of Issuance of 401 Water Quality Certiflcation: � ( GI—
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 requa�ed to retuin this certiFcate to the 401 Transportation Pe�mitting
Unit, North Carolina Division of Waier Quality, 1650 Mail Seivice Center, Raleigh, NC, 27699-1650. This form
may be retumed to NCDWQ by the applicant, the applicanYs authorized agent, or the project engineer. It is not
necessaiy to send certifica[es from all of these.
Applicmrt's Certifrcntiox
I, �� V I ����'�'LI/ lI�, 1�.T 1, hereby state that, to the best of my abilities, due care and diligence
was used in the observation o&fhe construction such that the construction was observed to be built within substantial
compliance and intent of the 401 Water Qualiry Certiffcation and Buffer Rules, the approved plans and
specifications, and er sup iYing materials.
Signature: Date: V —�
AgeuPs Certification
I, , hereby state that, to the best of my abilities, due care and diligence
was used in the observation of the wns[ruction such that the conshuction was observed to be built within substan[ia]
compliance and intent ofthe 401 Water Quality Certification and Buffer Rules, the approved plans and
specifications, and other supporting materials.
Signature:
Engiiieer's Certificntio�e
Partial Fina]
I, , as a duly registered Professiona] Engineer in the State of Noiih
Caz�olina, having been authorized to obseive (periodically, weekly, full time) the conshvetion of the project for the
Pernvttee hereby state that, to the best of my abilities, due care and diligence was used in the observation of the
consrivetion such that the conshuc[ion was obseived to be built within substantial complianee and intent of the 401
Water Quality Certification and Buffer Rules, the approved plans and specifications, and other supporting materials.
Signature
Date
NoM Camlina Dwision of Water �ualiry, Winslon-Salem Regional Off:e
Location: 585 Waughtown 5�. Win,�on-Salem, North Carolina 27107
Phone: [phone] FAX�. 336-771-06301 Cuslomer Service: 1-877b23-6748
Inlemet: wvnv.ncwate�qualiry.org
An Equal Opportunity 1 AKrmative Action Employer
Regish�ation No.
NorthCarolina
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