20161069 Ver 1_Certification of Completion_20170928

Action History (UTC -05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/28/2017 10:33:26 AM (Start)
BIMS Updated by Montalvo, Sheri A 9/28/2017 11:06:19 AM (Non DOT Project)
• The task was assigned to Montalvo, Sheri A 9/28/2017 10:33 AM

Water Resources
ENVIRONMENTAL QUALITY
Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all
mandatory questions are ansvtered.
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?* r Yes
rJ No
DWR Project #:* Version:*
20161069 1
County: Davie
401 Water Quality Certification Issued Date:
11/28/2016
Applicant: Town of Mocksville
Project Name: Quality Drive Extension
Supplemental Attachments: Click the upload button or drag and drop fileshere toattach docurrent
PDF only
Who will be submitting the Certification of
Completion?*
r Applicant
f Agent
r Certified Professional
If the project was designed by a Certified Professional:
I, as a duly registered Professional in the State of North Carolina, having been authorized to observe (periodically,
weekly, full time) 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 Buffer Rules, the approved plans and
specifications, and other supporting materials.
Type of Registered Professional: Engineer
Registration #: 17710
* rJ By checking the box and signing box below, I certify that
• I have given true, accurate, and complete information on this form;
• 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")
• 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");
• 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:* Charles A Willis Jr
Signature *