20160228 Ver 1_Certification of Completion_20170112

EWA
WCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory Donald R. van der Vaart
Governor Secretary
DWR Project No: /6—er-ni/ I County/: �oylnS-&-4
Applicant: Ttlwr-, a f// C�/��7�y11 Ldhn /Jr�/✓•(J/1(►1NOII-- /y/1Sf-
Project Name: 7V -0t, o L/,4n 4k, 5/vecoi /C,F1/'Ari/ drS��J%li_let�"t
401 Water Quality Certification Issued Date: W -i ez . ?K , ZO/&
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 DWR
401 & Buffer Permitting Unit, 1650 Mail Service Center, Raleigh, NC, 27699-1650. 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.
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.
Signature:
Agent's Certification
Date:
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:
Date:
If this wdaslaneb�tified Professional
I, 11YO"LY `. I"1r,
as a duly registered Professional 9&04.✓ (i.e.,
Engineer, Landscape Architect, Surveyor, etc.) in the State of North Carolina, having been authorized to
observe (periodically, `yeel.ly-rte,-` `.r;.e) the construction of the project, for the Permitee 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 B ry! les, the approved plans and specifications, and other supporting
materials. ( j
Signature: Date: /2/lN/ZL7Ile
7
I rQ-mizIL X. SWii-MJ
Al c t Unit _SS/
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FiVM dA11 Ma V9ery e�Qee
Raleigh, NorthCarolina 27699-1617 ,�L y,
do . 2 ii St, Raleigh, North Carolina 27604 ,
Phone: [phone] FAX: [phone] _ .15526
Internet: www.ncwaterquality.org
An Equal OppcMnityl Affirmative Action Employer— Made In pad by recycled papw � •"�'yGIIJ ���,-'�'}