HomeMy WebLinkAboutNCC230556_FRO Submitted_20230302FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Marion-Whiteville 115kV Line, Replace Switch 544 & 544-1
2. Location of land -disturbing activity: County Columbus City or Township Fair Bluff
Hinsons Crossroads 34.267969-79.006239
Highway/Street LatltUde(decimaldegrees) Long ltUde(decimaldegrees) _
3. Approximate date land -disturbing activity will commence: May 15, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Energy Infrastructure
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 10•8
6. Amount of fee enclosed $3,100.00 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name NUwan WiJesuriya E-mail Address nuwan.wijesuriya@duke-energy.com
Phone: Office # 919-546-2090 Mobile # 919-931-6655
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Utility Easement
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City
State Zip City
State
Zip
10. Deed Book No. Page No. 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).
Duke Energy Progress, LLC
Company Name
550 S. Tryon St., Ste 4500
Current Mailing Address
Charlotte, NC 28202
nuwan.wijesuriya@duke-energy.com
E-mail Address
410 S. Wilmington St.
Current Street Address
Raleigh, NC 27601
City State Zip City State Zip
Phone: Office # 919-546-2090 Mobile # 919-931-6655
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:
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)
(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:
CT Corporation System c/o Karen Rozar ct-statecommunications@wolterskluwer.com
Name of Registered Agent E-mail Address
160 Mine Lake Court
Current Mailing Address Current Street Address
Raleigh, NC 27615-6417
City State Zip City State Zip
Phone: Office # 919-844-8360 Mobile #
Karen Rozar
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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
HDR Engineering Inc. of the Carolinas
Engineering firm or other consultant
Wyatt D. Yelverton
Individual contact person (type or print)
wyatt.yelvert®n@hdrinc.co
E-mail Address
919-232-6623 919-389-6681
Phone: Office # Mobile #
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.
Nuwan Wijesuriya
Type or print name
111 44"
Signature
Lead Transmission Permitting Manager
Title or Authority
/O/3t 12.02.2.._
Date
I, $40<qo^ Gruj'Al^sk; a Notary Public of the County of LJake
State of North Carolina, hereby certify that UU WCUA U'esur11C% 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 day of Vc�jh:kr- , 20_Ag\_
Morgan Grudzinski - fi�
NOTARY PUBLIC Notary
Wake County, NC
My commission expires fli ly3 1;01S
My COmA61 Expires September 23, 2025