20110984 Ver 1_Certification of Completion_20191003

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/3/2019 1:39:23 PM (Start)
BIMSUpdated by EADS\klcarpenter 10/4/2019 12:06:11 PM (DOT Project)
• The task was assigned to EADS\klcarpenter 10/3/2019 1:39 PM

Staff Review
DWR Project #:* 20110984 Version:* 1
Reviewer List* Joanne Steenhuis:eads\jhsteenhuis
CERTIFICATION SUBMITTED ON 10/3/2019
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? V Yes
r- No
USACE Permit#
DWR Project #: 20110984 Version: 1
County: Bladen
401 Water Quality Certification Issued Date:
1/11/2012
Applicant: NCDOT Division 6
Project Name: B-4028 Replacement of Bridge Nos. 12, 18, & 42 on NC 11
Supplemental Attachments: Click the upload button or drag and drop files here to attach docurrent
PDF only
Who will be submitting the Certification of Completion?
r Applicant
r Agent
r Certified Professional
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.
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');
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
I intend to electronically sign and submit the "Certificate of Completion" form."
Printed Name: Gregory W. Price
Signature