20120776 Ver 2_Certification of Completion_20190215

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 answered.
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
V No
DWR Project M Version:*
120776 2
County: Watauga
401 Water Quality Certification Issued Date:
3/12/2018
Applicant: Town of Boone/John Ward, III
Project Name: Boone USDA Raw Water System
Improvements
Supplemental Attachments: aickthe upload button ordrag and drop fileshere toattach docurrent
2019-02-15 NCDEQ DWR 401 Cert of
234.53KB
Completion.pdf
FDF only
Who will be submitting the Certification of
Completion?*
r Applicant
r Agent
* 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 M 031444
* rJ 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)
0 1 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:* Ryan W. Hager
Signature