NCC231793_FRO Submitted_20230629

JOHNSTON COUNTY 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
Johnston County Department of Public Utilities. (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.
1. Project Name Williams Solar,LLC
2. Location of land-disturbing activity: City or Township Newton Grove
Harper House Road 35.278665 -78.368514
Highway/Street Latitude Longitude
December 1,2022
3. Approximate date land-disturbing activity will commence.
Commercial Solar
4 Purpose of development(residential, commercial, industrial, institutional, etc.):
5 Total acreage disturbed or uncovered (including off-site borrow and waste areas):36.1
6 Amount of fee enclosed S 7,125.00 The application fee of$380.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $125 per acre for each
additional acre(rounded up to the next acre). Individual residential lots plans are $100 per lot.
7 Has an erosion and sediment control plan been filed? Yes No Enclosed ✓
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name E-mail Address
Telephone Cell# Fax#
9 Landowner(s) of Record (attach accompanied page to list additional owners):
Carolyn Williams
Name Telephone Fax Number
8185 Harper House Road
Current Mailing Address Current Street Address
Newton Grove NC 28366
City State Zip City State Zip
10. Deed Book No Page No
Part B.
1 Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Williams Solar,LLC [e-mail]
Name E-mail Address
700 17th Street,Suite 700
Current Mailing Address Current Street Address
Denver, CO 20802
City State Zip City State Zip
720-400-8434
Telephone Fax Number

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:
Northwest Registered Agent Services,Inc. [e-mail]
Name E-mail Address
4030 Wake Forest Road,STE 349
Current Mailing Address Current Street Address
Raleigh NC 27609
City State Zip City State Zip
Telephone _ 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Brandon Canard Manager of Financially Responsible Person
Type or print name Title or Authority
12/20/2022
Signature Date
I, Gloke.r. Ma Ion c_y . a Notary Public of the County of ?€n vc r
GO{OrA.ao Q
State of 4orth Carolina, hereby certify that pr(^n1 r. Lonq.ra Mwhiki r appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 2- day of Q c c c,v (,t r , 20 a Z,
STEPHEN MALONEY
setory Public
State of Colorado My commission expires 07 /0 8 /zoz Io
Notary ID#20224026729
My Commission Expires 07-08-2026