NCC241156_FRO Submitted_20240430

Check if this project is ARPA-funded El
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 The Oaks Subdivision
*If this project involves American Rescue Plan Act(ARPA)funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure(DWI).
NA
2. Location of land-disturbing activity: County Granville County City or Township Wake Forest
Bruce Garner Rd 36.082798 -78.575816
Highway/Street Latl'Um e(decimal degrees) LongltUde(decimai degrees)
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 100.21
6. Amount of fee enclosed: $ 10,100 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 N CDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑✓ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Rick Grote E-mail Address [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Nora G Mckeithan
Name Phone: Office# Mobile#
1308 Pilsdon Crest
Current Mailing Address Current Street Address
Mount Pleasant, SC 29464
City State Zip City State Zip
10 Deed Book No.252 Page No 54 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)maybe listed as the financially responsible party(ies).
Greenpointe, LLC [e-mail]
Company Name E-mail Address
7201 Creedmoor Rd Ste 140 7201 Creedmoor Rd Ste 140
Current Mailing Address Current Street Address
Raleigh NC 27613 Raleigh NC 27613
City State Zip City State Zip
Phone: Office# 919-457-8402 Mobile#[phone]
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:
Greenpointe, LLC [e-mail]
Name of Registered Agent E-mail Address
7201 Creedmoor Rd Ste 140 7201 Creedmoor Rd Ste 140
Current Mailing Address Current Street Address
Raleigh NC 27613 Raleigh NC 27613
City State Zip City State Zip
Phone: Office# 919-457-8402 Mobile# [phone]
Jeff Grote
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:
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)

(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
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.
Jeff Grote Manager
Type or print name Title or Authori
Si ure Date
I, Ahv2. L/ Ub)i'161)h , a Notary Public of the County of da/i!Z
State of North Carolina, hereby certify that U:frf 603' 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 84 day of (10e l e-( , 20 23
41-1-474-- Iqs:9-ik/v -
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Date: 1L- 1L/ -2'I23
We,Nora M. Coker(Formerly Nora G McKeithan)and Malcolm L McKeithan III, do hereby grant our
consent for Greenpointe,LLC,to apply for any necessary permits needed to perform land disturbing
activities for the construction of the Oaks Subdivision on our property located on Bruce Garner Rd,Wake
Forest, Granville County,NC,being identified as Parcels 1824-49-6235, 1824-51-1182, 1824-59-8425,
&1824-59-6399.These parcels are identified in Deed Book 199,PG 270; Deed Book 241,PG 316;Deed
Book 241,PG 334;Deed Book 252, PG 540. Let it also be known that Greenpointe,LLC will not
commence any land disturbing activities until all appropriate permits have been obtained, and that state
approvals are met and the deed has been officially transferred making Greenpointe, LLC the owner of
said property.
Signed 77 �- �/� fisityL , NV
Nora M. Coker Malcolm L McKeithan III
County,North Carolina
I certify that the following person personally appeared before me this day, acknowledging that he or she
signed the foregoing document.
Name of Principal: / /C1(A. Op�/t l/ M0,Ico/m J.< <'I G 1 c
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Date: ZOZ3
Official Seal __ 4l/ 44441A1
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My commission expires: 9h l-/ZOL y