NCC243519_FRO Submitted_20241113

.44,)„) CITY OF GREENS> ORO
FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity covered by the Sedimentation Pollution Control Act before this form
has been completed and filed with the Sediment and Erosion Control Section of the City of Greensboro. (Please type
or print and, if questions are not applicable, place N/A in the blank).
Part A:
1. Project Name: McConnell Ridge Phase 1 Single Family
2. Location of land-disturbing activity: 4453 McConnell Road,McLeansville,NC 27301
3. Approximate date land disturbing activity will be commenced: September2023
4. Development type: Commercial_ Industrial_ Institutional_ MF residential_SF residential ✓
5. Approximate acreage of land to be disturbed: 24.87 AC
6. Has an erosion and sediment control plan been filed? Yes ✓ No (Included with submittal)
7. Landowner(s)of Record (attach pages to list additional owners):
AF-McConnell,LLC 336.420-8600 bjackson@greenhawkcorp.
Name Telephone Email
1330 Sunday Drive,Suite 105 1330 Sunday Drive,Suite 105
Current Mailing Address Current Physical Street Address
Raleigh NC 27607 Raleigh NC 27607
City State Zip City State Zip
8. Deed County: Guilford Book: 8577 Page: 915
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Blayne Jackson Telephone: [phone]
E-mail: [e-mail] Other:
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.
AF-McConnell,LLC 336-420.8600 bjackson@greenhawkcorp.
Name Telephone Email
1330 Sunday Drive,Suite 105 1330 Sunday Drive,Suite 105
Current Mailing Address Current Physical Street Address
Raleigh NC 27607 Raleigh NC 27607
City State Zip City State Zip

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 Telephone Email
Current Mailing Address Current Physical Street Address
City State Zip City State Zip
(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 Telephone Email
Current Mailing Address Current Physical Street Address
City State Zip City State Zip
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.
.VJ131 6eneral-PAanager(Agarwal Family Ill,LLC) Goo
Typ print na e Title or Authority
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, a Notary Public of the County of IrrO���
State of A/0 cerol:f‘ i , hereby certify that ` elrf'tay k
Personally accepted before me this day and under oath acknowledged that the above form was
executed by owner(s).
Witness my hand and notarial seal, this day of , 20
My Commission expires I/� } ) i
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