NCC216776_FRO Submitted_20211208

N&T #21137
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 Environment and Natural Resources. (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.
1. Project Name Westgate Townhouses
2. Location of land -disturbing activity: County Brunswick
Highway/Street Westgtate Dr
City or Township
Leland
Latitude 340 12' 32" Longitude
3. Approximate date land -disturbing activity will commence
Jan 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
-78" 0' 33"
Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 25
6. Amount of fee enclosed: $ 1,625.00 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 X No
Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name J. Phillip Norris, P.E. E-mail Address [e-mail]
Telephone [phone] Cell # 910471-9638 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
WGTRACT5, LLC 1 WGTRACT6, LLC 910-791-1196
Name Telephone Fax Number
P.O. Box 3167 2201 Burnett Blvd.
Current Mailing Address Current Street Address
Wilmington NC 28406
City State Zip
10. Deed Boole No. 3599/3599
Part B.
Page No.
_Wilmington NC 28401
City State Zip
1116/1124
Provide a copy of the most current deed.
1. 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):
Encore at Westgate Townhomes, LLC
Name
200 E. Broad Street, Suite 220
Current Mailing Address
Greenville Sc 29601
City State
Telephone [phone]
[e-mail]
soeterson(@GravcliffCaoital
E-mail Address
200 E. Broad Street, Suite 220
Current Street Address
Greenville Sc 29601
Zip City
Fax Number
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:
Incorp Services, Inc.
Name
176 Mine Lake Court, Suite 100
Current Mailing Address
Raleigh NC 27615
City State Zip
Telephone
NIA
NIA
Email Address
Current Street Address
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
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 fonri must be signed by the Financially Responsible Person if an individual or his attomey-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.
Paul
General Partner, GrayBui Westgate, LP
Title or Authority
IV1q/?.y-LI
Date
1, a Notary Public of the County of G re e /Iy - t
State of North Carolina, hereby certify that a. tk- S r
appeared personally before me this day and being duly sworn acknowledged that the above form was
executed by him. Gr `
Witness my hand and notarial seal, this J day of , 20 �-
/1 1 e" }— L
Seal
My commission expires AU � t& S
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NT# 21137
Financial Responsibility/Ownership Form
Sedimentation Pollution Control Act
Westgate Townhouses
Landowner Attachment
9. Landowner of Record (Owner #2)
WG MM TRACTS, LLC & WG MM TRACT6, LLC
Mark L. Maynard, Manager
10 S Cardinal Drive
Wilmington, NO 28403-1843
910-251-5030
[e-mail]
10. Deed Book: 3599/3599 Page No.: 1116/1124