NCC224051_FRO Submitted_20221213

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name New Building Site - 2611 Hospital Rd.
2. Location of land -disturbing activity: County Wayne City or Township Goldsboro
Highway/Street Hospital Road 35.4038°N-77.9546*w
Latitude(decimal degrees) LOngltUde�decimal degrees}
3. Approximate date land -disturbing activity will commence: November 21, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5_ Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.00
6. Amount of fee enclosed: $ 200.00 . The application fee of $100,00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No E]
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Scott Edwards E-mail Address [e-mail]
Phone: Office # 919-751-5100 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Group W Holdings, LLC 919-736-0087 919-921-1501
Name Phone: Office # Mobile #
PG Box 10273 307 N. Claiborne Street
Current Mailing Address Current Street Address
Goldsboro NC 27532-0273 Goldsboro NC
City State Zip City
10. Deed Book No. 2944 Page No. 280
State
27530
Zip
Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Group W Holdings, LLC
Company Name
PO Box 10273
Current Mailing Address
Goldsboro NC 27532-0273
[e-mail]
E-mail Address
307 N. Claiborne Street
Current Street Address
Goldsboro NC 27530
City State Zip City State Zip
Phone: Office # 919-736-0087 Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
C. Brian Woodard
[e-mail]
Name of Registered Agent
E-mail Address
PO Box 10273
307 N. Claiborne Street
Current Mailing Address
Current Street Address
Goldsboro NC 27532-0273
Goldsboro NC 27530
City State Zip
City State Zip
Phone: Office # 919-736-0087
Mobile # [phone]
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State Zip
City State Zip
Phone: Office #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA_Name
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
C. Brian Woodard
Signature
Member
Date
1, ec Wl -,a Notary Public of the County of
Wayne
State of North Carolina, hereby certify that C. Brian Woodard appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this L day of ( �%tO� 20 1,_Z -_
Notary
My commission expires