NCC220918_FRO Submitted_20220301

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 Arthur's Creek - Phase 2
2. Location of land -disturbing activity: County Wayne City or Township Fork Townshi
Highway/Street Charlie Braswell Road River Basin: Neuse
Latitude N 35.4247 Longitude W-78.0999
(Lat and Long given to 4 decimal places it XX.xxxx N,-YY.yyyy W. not XX xx'xx" N, -YY yy' yy" W)
3. Approximate date land -disturbing activity will commence: February, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.0
6. Amount of fee enclosed: 600 The application fee of $100 $655.00 per acre (rounded up to the next
acre) is assessed without a ceiling amount (Example: a 9-acre application fee is5).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name David M. Perry E-mail Address dperry6961(Waol.COm
Telephone [phone] Cell # [phone] Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Builders Bargain Center of Kinston Inc.
Name
PO Drawer E
Current Mailing Address
Goldsboro NC 27533
City State Zip
[phone] [phone]
Telephone Fax Number
701 Patetown Road
Current Street Address
Goldsboro NC 27530
City State Zip
10. Deed Book No. 3518 Page No. 603 Provide a copy of the most current deed.
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):
Builders Bargain Center of Kinston, Inc. [e-mail]
Name E-mail Address
P.O. Drawer E 701 Patetown Road
Current Mailing Address Current Street Address
Goldsboro NC 27533 Goldsboro NC 27530
City State Zip City State: Zip
Telephone [phone] Fax# [phone]

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 State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
Fax#
(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 State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
Fax#
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 by any change in the information provided herein.
David M. Perry
Type or print name
Signature
Registered Agent
Title or Authority
l�-M Z' -
Date
I, Doris S. McFatter a Notary Public of the County of Wayne
State of North Carolina, hereby certify that appeared personally before
me this day and being duly sworn acknowledged that the ove for was executed by him.
Witness my hand and notarial seal, this day of , 2C`
`,Illaltiitfru11/j/. %
pQ�5 S. MF,��,�i,1��i
4 TF� Notary Doris S. McFAtter
CRY
My commission expires January 13'" 2026
PUBLIC ) E
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101111l11111�1

B. R. KORNEGAY, INC.
LAND SURVEYING . ENGINEERING • PLANNING
300 E. Walnut Street
Goldsboro, North Carolina 27530
www,kornegaysep.com [phone] Fax: [phone]
Firm No. F-1054
January 24, 2022
NCDEQ
Energy, Mineral and Land Resources
Washington Regional Office
943 Washington Square Mall
Washington, N.C. 27889
Project: Arthur's Creek -Phase 2
Charlie Braswell Road
Goldsboro, NC
Wayne County
Please find enclosed the following items for your review and approval.
1. Completed financial responsibility form.
2. Check from Goldsboro Builder's Supply in the amount of $600 for 6.0 acres of proposed
disturbed land.
3. Two sets of construction drawings.
4. Two sets of storm water calculations.
5. Two copies of specifications.
6. Copy of NCDEQ 401 Water Quality Certification approval.
7. Copy of U.S. Army Corps of Engineers permit.
Please contact me if you need any further information.
Sincerely,
Jeffrey L. Kornegay, PE, PLS