NCC240408_FRO Submitted_20240220

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 Cornbread Valley Mitigation Site
2. Location of land-disturbing activity: County Macon City or Township Franklin
1765 N Jones Creek Road 35.101330 N -83.455015 W
Highway/Street Latitude(decimal degrees) Long itude(decimal degrees)
3. Approximate date land-disturbing activity will commence:
Stream and Wetland Mitigation
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 26 ac
6. Amount of fee enclosed: $2600 . 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 ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jake McLean E-mail [e-mail]
Phone: Office# (828)-774-5547 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
See attached
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).
Wildlands Engineering, Inc. [e-mail]
Company Name E-mail Address
167-B Haywood Road 167-B Haywood Road
Current Mailing Address Current Street Address
Asheville, NC 28806 Asheville, NC 28806
City State Zip City State Zip
Phone: Office# (828)-545-3865 Mobile#
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:
N/A
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:
Shawn D.Wilkerson, Registered Agent/Manager [e-mail]
Name of Registered Agent E-mail Address
1430 South Mint Street, Suite 103 1430 South Mint Street, Suite 103
Current Mailing Address Current Street Address
Charlotte, NC 28203 Charlotte, NC 28203
City State Zip City State Zip
Phone: Office# [phone] Mobile# [phone] (fax)
Name of Individual to Contact(if Registered Agent is a company)

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.
Shawn D. Wilkerson President
Type or print name Title or Authority
1/19/2023
Signat a Date
I, 4jA/lo / k;nil ety. , a Notary Public of the County of `✓)e,G4/0 , it/
!k State of North Carolina, hereby certify that `jhg`Vn ahtoappeared 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 Ili day of JarNt, k , 20 2
fliJvy
�= Notary
CHARLO�� P. Kie.NEY
NOTARY PUBLIC My commission expires // / $ 747'2 6
Mecklenburg County; North Camllna.,