20121039 Ver 1_SR 1321 Madison DWR Completion Form_20161128

North
Be�erly Eaves Perdue
Governor
Q��
NCDENR
Carolina Department of Environment and Natural Resources
Division of Water Quality
Chades Wakild, P.E Dee Freeman
Director Secretary
DWQ Project No.: �I�r�✓'`
Applicant;
Project Nan
Date oP Issu
County: /�'lG��l$UY'1
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 retum this certificate to the 401 Transportation Permitting
Unit, Nmth Carolina Division of Wa[er Quality, 1650 Mail Service Center, Raleigh, NC, 27699-1650. This form
may be returned to DWQ by the applicant, the applicanPs authorized agent, or the project engineer. It is not
necessary to send certificates from all of these.
App anPs Certi cation p
�. � p .ur��l1 o�i Pl /1 ,Qruoahereby state that, to the best of my a6ilities, due care and diligence
was u in the obs�ation of th wnstruction 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 suppor[ing materials.
Signature: � ,f-P.� � 1Di�,��r� Date: � � y �U/
�T—�
Agent's Certification
1, _ , hereby state that, to Ihe 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
l, , 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 o[her supporting materials.
Signature Registration No.
Da[e
7617 Mail Service Center, Raleigh, North Carolina 27699-1617
Locafron: 572 N. Salls6ury St. Raleyh, Nodh Carolina 27604 Qpe
Phone; 91 9-801-63 00 1 FAX: 979-807-fi4921 Customer Service:1-877-623-fi748 NorthCarolina
InterneC wvrN.ncwaterquality.org �i�turall�
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