NCC216223_FRO Submitted_20211112

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 NameWindcrest Acres Subdivision Section 3
2. Location of land -disturbing activity: County Randolph City or TownshipAsheboro
Highway/StreetWindcrest rd. Latitude35.745734 Longitude-79.795050
3. Approximate date land -disturbing activity will commence:Aug. 2nd 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 15.5 ac.
6. Amount of fee enclosed. $1 ,040.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No EnclosedYes
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameLanny Hedrick E-mail Address [e-mail]
Telephone[phone] Cell # 336-479-6676 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Davidson Land Development, LLC 336-746-5515 N/A
Name Telephone Fax Number
5930 E. Old Hwy_ 64 Same
Current Mailing Address Current Street Address
Lexington NC 27292 Same
City State Zip City State Zip
10. Deed Book No.2202 Page No 1 072 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.
Davidson Land Development, LLC chris@_ reidfarm.com
Name E-mail Address
5930 E. Old US Hwy 64
Current Mailing Address
Lexington NC 27292
City State Zip
Telephone [phone]
Same
Current Street Address
Same
City State Zip
Fax Number N/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
Name
N/A
Current Mailing Address
N/A
City State Zip
Telephone N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
City State Zip
Fax Number N/A
(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:
N/A N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
City State Zip
Telephone N/A
E-mail Address
N/A
Current Street Address
N/A
City State Zip
Fax Number N/A
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.
James Christopher Reid
4Typ or print n me
Si ature
Registered Agent
Title or Authority
6 - 28- 202. r
Date
I, _?)e6ndq � Cc)v i,o Of` , a Notary Public of the County of
ba v Id son
State of North Carolina, hereby certify that --TQ- m e5 L.hri slo �cl d 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 �9_day of -u.n e , 20 a I
— - &&'nsa 4 oa
BELINDA H COVINGTON Notary
SW
ary Public - North Carolina
Davidson County My commission expires_
My Commission Expires Sep 26, 2025