NCC241240_FRO Submitted_20240422

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.
1. Project Name Hawthorne at Concord Lake
2. Location of land-disturbing activity: County Cabarrus City or Township Kannapolis
Highway/Street Concord Lake Rd Latitude 35.467252 Longitude -80.602212
3. Approximate date land-disturbing activity will commence: August 2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 19.65 AC
6. Amount of fee enclosed: $ $2000 . 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).
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 John Holcomb E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Hawthorne Concord Lake Apartments, LLC. 910-239-9120
Name Telephone Fax Number
806 Green Valley Rd,Suite 311 2012 Eastwood Rd
Current Mailing Address Current Street Address
Greensboro NC 27408 Wilmington NC 28403
City State Zip City State Zip
10. Deed Book No. 11437 Page No. 76 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 or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Hawthorne Concord Lake Apartments, LLC. [e-mail]
Name E-mail Address
806 Green Valley Rd, Suite 311 2012 Eastwood Rd
Current Mailing Address Current Street Address
Greensboro NC 27408 Wilmington NC 28403
City State Zip City State Zip

Telephone [phone] 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:
Name E-mail Address
Current Mailing Address Current Street Address
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.
Type or print name Title or Authority
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Signature r Date
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I, U On "'i Lx. .747, , a Notary Public of the County of uc 1- l 0
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand anct a it al afar is da f ` ( , 20-37 _.
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K.,
ROY COOPER srA7t
Governor
e-i ,„1„
ELIZABETH S.BISER
Secretary
ri 4
BRIAN WRENN
Director NORNOH CAROLIN A
Environmental Quattly
December 20,2021
LETTER OF RECEIPT OF EROSION CONTROL PLAN
Hawthorne Concord Apartments,LLC
Attention: Mike Winstead,Manager
806 Green Valley Road,Suite 311
Greensboro North Carolina 27408
RE:
Project Name: Hawthorne at Concord Lake
Project ID: CABAR-2022-046
County:Cabarrus
Project Location: Concord Lake Drive
Submitted By: Kimley Horn
Date Received by LQS:December 17,2021
Plan Type:New
ESC Plan Reviewer: Chris Graybeal
Dear Mr. Winstead:
This office has received an erosion and sediment control (ESC)plan for the project listed above which
was submitted as required by the North Carolina Sedimentation Pollution Control Act (G.S. 113A-57
(4)).
We have performed a preliminary review of your submitted plan and have determined that
additional information should be submitted before a full ESC plan review can be completed.
Attached is a checklist of items that must be submitted before we can complete the ESC plan
review process. Be advised failure to provide the additional information may result in disapproval
of your plan. Please direct all inquiries and response to the ESC plan reviewer listed above and
list the Project ID Number on all correspondence. All information should be submitted no later
than 20 days after the received date listed above.
The Act requires that all persons disturbing an area of one or more acres of land must obtain approval of
a soil erosion control plan prior to the commencement of the land-disturbing activity (U.S. 113A-54(d)
(4)). The Act further states that this plan must be filed a minimum of 30 days prior to the activity and
the approving authority must approve or disapprove the submitted plan within 30 days of receipt.
Failure of the approving authority to approve or disapprove the submitted plan within the 30-day period
will be deemed approval of the plan.
c14..
North Carolina Department of Environmental Quality Dwaine of Energy,Mineral and Land Resources
Mooresville Regional Office 1610 East Center Avenue,Suite 3011 Mooresville,North Carolina 28115
704-663.1699
emou\sugied

Letter of Receipt
Hawthorne Concord Apartments, LLC
December 20, 2021
Page 2 of 3
Commencement or continuation of a land-disturbing activity under the jurisdiction of this Act prior to
the approval of an erosion and sediment control plan is a violation of the Act
The approval of an erosion and sediment control plan is conditioned on the applicant's compliance with
Federal and State water quality laws,regulations and rules.
If you have questions, please do not hesitate to contact the ESC plan reviewer listed above. Your
cooperation in this matter is appreciated and we look forward to working with you on this project.
7
Sincerely, /
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Ke lywelyn
E ; mental Se ' r, cialist
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2 • d Quality Sec on
27
c: Kimley Horn
Attn: John Holcomb
200 South Tryon Street, Suite 200
Charlotte,NC 28202

Letter of Receipt
Hawthorne Concord Apartments,LLC
December 20,2021
Page 3 of 3
APPLICATION CHECKLIST ITEMS
IDENTIFIED DURING PRELIMINARY REVIEW
• Please verify the North Carolina Registered Agent on the FRO form. The North Carolina
Department of the Secretary of State website has corporation information available at
http://vvvv-w.secretary.state.ne.usisearchlindexicorp. [G.S, 113A-54.1]