NCC216260_FRO Submitted_20211110

JOHNSTON COUNTY 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
Johnston County Department of Public Utilities. (Please type or print and, if the question is not applicable or
the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
Project Name Copper Creek South , Phase 2 - Lots 26, 52, 56, 58 & 59 _
2. Location of land -disturbing activity: City or Township Banner Township
Boulder River Trail
Highway/Street & Ravens Row Drive Latitude N 35.4231' Longitude W-78.5480'
3. Approximate date land -disturbing activity will commence: September 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.64 Acres
6. Amount of fee enclosed: $ 990.00 . The application fee of $330.00 per acre (rounded up to
the next acre) is assessed for the first 10 acres and an additional $110 per acre for each additional
acre (rounded up to the next acre).
7 Has an erosion and sediment control plan been filed? Yes No Enclosed XXX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jamie Godwin E-mail Address Jamie(a)-agresidential nc.com
Telephone [phone] Cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
_R P Wellons Land & Development, LLC
Name Telephone Fax Number
PO Box 730 2004 W. Cumberland Street
Current Mailing Address Current Street Address
Dunn NC 28335 Dunn NC 28334
City State Zip City State Zip
Lot 52 Lot 52
10. Deed Book No. 5249 Page No. 545
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
A & G Residential, LLC
Name
916 Arsenal Avenue, Suite B
Current Mailing Address
Fayetteville NC 28305
City State Zip
Jamie(d)-agresidentialnc.com
E-mail Address
Same
Current Street Address
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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
Current Mailing Address
City
Telephone.
E-mail Address
Current Street Address
State Zip City State Zip
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.
Jamie Godwin
Type or print name
Signatur 1
Member -Manager
Title or Authority
lizTI
Date
I, ga hm,ne. A. Z oiaS a Notary Public of the County of Cup be-p laM
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 and notarial seal, this
Seal
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Landowners) of Record (attach accompanied page to list additional owners):
A & G Residential, LLC 910-237-7944
Name Telephone Fax Number
916 Arsenal Avenue, Suite B Same
Current Mailing Address Current Street Address
Fayetteville NC 28305 Same
City State Zip City State Zip
Lots 26,56,58&59 Lots 26,56,58&59
10. Deed Book No. 6050 Page No. 493