NCC230616_FRO Submitted_20230307

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Two Hearted Solar
1. Project Name
2. Location of land -disturbing activity: County Yadkin City or Township Unincorporated
Highway/Street shady Grove church Road Latitude 36.236317 N Longitude-80.55745 W
3. Approximate date land -disturbing activity will commence: September 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Solar Energy
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 205
6. Amount of fee enclosed: $ $13,325 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Tripp MCSwain E-mail Address [e-mail]
Telephone Cell # 704-457-7004 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Billy G. Miller
PIN:
5940470983 Name
Telephone Fax Number
3237 Arnold Road
3237 Arnold Road
Current Mailing Address
Current Street Address
Hamptonville NC
27020 Hamptonville NC 27020
City State
Zip City State Zip
10, Deed Book No. 92
Page No. 367 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who
are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Pine Gate Renewables
[e-mail]
Name
E-mail Address
130 Roberts Street
130 Roberts Street
Current Mailing Address
Current Street Address
Asheville NC
28801 Asheville NC 28801
City State
Zip City State Zip
Telephone [phone] Fax Number

CONTINUATION OF LANDOWNER(S) OF RECORD
Landowner(s) of Record (attach accompanied paqe to list additional owners):
PIN:
593012869954 Evan R Williams & Tina B. Williams
594000183265 Name
591000177577 1029 J&K Farm Road
593012978009 Current Mailing Address
East Bend NC 27018
City State Zip
Telephone Fax Number
1029 AK Farm Road
Current Street Address
East Bend NC 27018
City
State
Zip
Deed Book No. 1107 Page No.
94
Provide a copy of the most current deed.
Deed Book No. 1054 Page No.
1
Provide a copy of the most current deed.
Deed Book No. 1055 Page No.
9
Provide a copy of the most current deed.
Deed Book No. 10E Page No.
402
Provide a copy of the most current deed.
Landowner(s) of Record (attach accompanied page to list additional owners):
��
5940076385 Jackie Williams
594000168827 Name Telephone
3127 Smithtown Road 3127 Smithtown Road
Current Mailing Address Current Street Address
East Bend NC 27018
City State Zip
East Bend NC
City
State
Fax Number
27018
Zip
Deed Book No. 75 Page No. 463 Provide a copy of the most current deed.
Deed Book No. 364 Page No. 597 Provide a copy of the most current deed.
Landowner(s) of Record (attach accompanied page to list additional owners):
Ruth P. Matthews & Carl V. Matthews
PIN: Name
593012962052
594000155918 3137 Smithtown Road
5940068793 Current Mailing Address
593012958477 East Bend NC 27018
PIN:
594000372744
City
State
Telephone Fax Number
3137 Smithtown Road
Current Street Address
East Bend NC 27018
Zip City
State
Zip
Deed Book No. 1227
Page No.
443
Provide a copy of the most current deed.
Deed Book No. 762
Page No.
127
Provide a copy of the most current deed.
Deed Book No. 736
Page No.
347
Provide a copy of the most current deed.
Deed Book No. 736
Page No.
347
Provide a copy of the most current deed.
Landowner(s) of Record (attach accompanied page to list additional owners):
Jesse Pearl Smitherman
Name
Telephone
Fax Number
4344 Shady Grove Church Road 4344 Shady Grove Church Road
Current Mailing Address Current Street Address
East Bend
City
Deed Book No
NC 27018 East Bend NC
State Zip City State
27018
Zip
1388 Page No. 1456 Provide a copy of the most current deed.

City
CONTINUATION OF LANDOWNER(S) OF RECORD
Landowner(s) of Record (attach accompanied page to list additional owners):
PIN:
594000262984 Shady Grove Partners LLC
594000265886 Name
594000362982 1040 Hoot Owl Hollow Road
Current Mailing Address
East Bend NC 27018
State Zip
Telephone
Fax Number
1040 Hoot Owl Hollow Road
Current Street Address
East Bend NC 27018
City
State
Zip
Deed Book No. 1102
Page No.
145
Provide a copy of the most current deed.
Deed Book No. 1172
Page No.
78
Provide a copy of the most current deed.
Deed Book No. 1172
Page No.
78
Provide a copy of the most current deed.

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
Telephone
State
E-mail Address
Current Street Address
Zip City State Zip
Fax Number
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
�e r1 �Cl'1T
Type or ame
Signature
cy
Title or Authority
I.2. Zu2►
Date
I, 1Yt, OVu Vv u tt, nr\fAvivN , a Notary Public of the County of
State of North Carolina, hereby certify that r-'6eA Ck W appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. ii
Witness my hand and notarial seal, this 2rtd day of J L) 20 21
` %%jIIfill,
Seal `p� ssw�<<I �,� Not
M Oil% •. ?+ .
�f�:�Z_ M commission expires
A `
NO R►- �: z= p
W ;� �"rn:
7' 0- C PUBLIC : V —
P: —
i