20070498 Ver 1_Sampson B-4271 401 Completion Form_20190621

Water Resources
ENVIRONMENTAL QUALITY
NCDWR Project No.: _ 20070498 Ver. l -2
Applicant: NCDOT PDEA
Project Name:
B-4271- Bridge 98 on SR 1246
Date of Issuance of 401 Water Quality Certification:
County
6/28/2007
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Sampson
Secretary
S. JAY ZIMMERMAN
Director
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 401 Transportation Permitting
Unit, North Carolina Division of Water Resources, 1617 Mail Service Center, Raleigh, NC, 27699-1617. This form
may be returned to NCDWR 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:
1, Mason Herndon , 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.
—M.... H Meson Herndon
y � _ cn=Mason Herndon, o. ❑e,—rt .totTmnsporUtbn. 6/ 1 9/ 1 9
ow0ivision 3, email=M1nhemtlon@nrdoLgov, c=US
Signature: oae:2ois:o5a91427:z1-oanv Date:
Engineer's Certification
Partial Final
I, , 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 other supporting materials.
Signature
Date
Registration No.
State of North Carolina lEnvironmental Quality I Water Resources
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Phone:[phone]