NCC215506_FRO Submitted_20211005

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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. Drill Test Site Project Carolina Belle, LLC
1. Project Name
2.
3.
4.
5.
6.
Location of land -disturbing activity: County Montgomery City orTownshipCandor
Highway/StreetG'old mine Rd Latitude35.310334 _Longitude-70.788068
Approximate date land -disturbing activity will commence: Sept' 20 2021
Purpose of development (residential, commercial, industrial, institutional, etc.). Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5
Amount of fee enclosed. The Express Permitting application fee is a dual charge.
The normal fee of $65.00 p r al4e is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No Enclosedx
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Nay„e,lonathan Powers E-mail [e-mail]
Telephone[phone] Cell # 919-632-0444 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Angus Realty Corporation [phone] n/a
Name Telephone Fax Number
PO Box 511 209 West Currie Rd
Current Mailing Address Current Street Address
Candor NC 27229 Candor NC 27229
City State Zip City State Zip
10. Deed Book No. 251 Page No. 745 Provide a copy of the most current deed.
Part B.
1. Company(les) 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 compy orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Project Carolina Belle, LLC [e-mail]
Name E-mail Address
204 Bernard Purvis Rd 204 Bernard Purvis Rd
Current Mailing Address Current Street Address
Bennett NC 27208 Bennett NC 27208
City State Zip City State Zip
Telephone[phone] Fax Numbern/a

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:
n/a n/a
Name E-mail Address
n/a n/a
Current Mailing Address
n/a
City State
Telephone n/a
Current Street Address
n/a
Zip City
Fax Number n/a
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:
Jonathan Powers
Name of Registered Agent
204 Bernard Purvis Rd
Current Mailing Address
Bennett NC 27208
City
State Zip
Telephone [phone]
[e-mail]
E-mail Address
204 Bernard Purvis Rd
Current Street Address
Bennett NC 27208
City State Zip
Fax Number n/a
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Summey Engineering. Associates, PLLC [e-mail]
Engineering Firm or other consultant E-mail Address
Christian Vestal 336-328-0902 336-328-0922
Individual contact person (type or print) 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.
Jonathan Powers Vice President
Type or print nam
5i ature
-----------------------------------------
Title or Authority
9/T 20Zi
Date
I, a Notary Public of the County of C-?anCU)10h
State of North Carolina, hereby certify that s 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 8-0- day of 20 21
(L)0"
NGtafy-"
Seal
My commission expires S - Z4 - 2,025;-