NCC221116_FRO Submitted_20220322

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Samaritan's Purse Inn
2. Location of land -disturbing activity: County Wilkes City or Township North Wilkesboro
Highway/StreetWhite Pine Street Latitude(decimaldegrees) 36.186035 Long ltude(decimaldegrees) -81.138566
3. Approximate date land -disturbing activity will commence: March 141 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Lodge
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.50
6. Amount of fee enclosed $500.00* . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ. *SEE ATTACHED EMAIL -THIS IS A MODIFICATION & PRIOR PAID FEES APPLY
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJason Blackwell E-mail [e-mail]
Phone: Office # 336-846-4266 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Samaritan's Purse 828-278-1511 828-262-1980
Name Phone: Office # Mobile #
P.O. Box 3000 801 Bamboo Road
Current Mailing Address Current Street Address
Boone NC 28607 Boone NC 28607
City State Zip City State Zip
10. Deed Book No. 1184 Page No. 433 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the companyis a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Samaritan's Purse [e-mail]
Company Name E-mail Address
P.O. Box 3000 801 Bamboo Road
Current Mailing Address Current Street Address
Boone NC 28607 Boone NC 28607
City State Zip City State Zip
Phone: Office # 828-278-1511 Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, 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 Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General

Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
(d) If 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:
EMH&T
Engineering firm or other consultant
Brian Rossi
Individual contact person (type or print)
[e-mail]
E-mail Address
614-775-4370 980-259-8797
Phone: Office # Mobile #
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Ronald E. Wilcox
Type or pri name
Signature
Chief Operating Officer
Title or Authority
Date
I, "re'w MG , a Notary Public of the County of WLt_Gwyt;Dl
State of North Carolina, hereby certify that IZOtIAW E • W; I60)< appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 17
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Seal
NOTARY PUBLIC
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*FEE VERIFICATION EMAIL`
Rossi, Brian
From: Lentz, Zachary <[e-mail]>
Sent: Wednesday, January 26, 2022 9:00 AM
To: Rossi, Brian
Cc: Heslep, Brandon
Subject: RE: [External] SP Inn - NCDEQ Erosion and Sediment Control Review
HI Brian,
need you to clarify if you'd like to set up an express review or do a regular revision. Assuming no new acreage:
Regular:
No additional fee
The review is initiated upon receipt of a new FRO Form and revised plans with a narrative summary of the changes and
clouded changes on the plan sheets.
I may send comments or request a meeting to discuss the revisions after I've reviewed the submittal depending on how
quickly I can get to it.
The plan must be approved or disapproved within 15 days of receipt.
Express:
$500 additional fee (with no new acreage, the revised express fee is simply half the original express fee)
The review is initiated by scheduling a pre -application meeting, during which the revisions are summarized and we
discuss any additional changes needed.
If there is a need for additional comments/clarifications, l will send a detailed list, typically within one day of our
meeting.
The plan must be approved or disapproved within 15 days of receipt, but plans accepted for the express program are
typically approved within one week of our meeting.
In either case, I'm happy to review a PDF of the plan and accept a revised set upon approval, but I'll need the FRO Form
(and possibly fees) in order to approve. Please let me know if you have any questions and what route you decide on.
Thanks,
Zac
Zac Lentz, PE
Assistant Regional Engineer
Division of Energy, Mineral, and Land Resources
Department of Environmental Quality
33 6-776-9661 (office)
[e-mail]
450 W. Hanes Mill Rd, Suite 300
Winston Salem NC 27105

ROY COOPER
Governor FOR REFERENCE:
DIONNE DELLI-GATTI PREVIOUSLY
Secretary APPROVED PERMIT
BRIAN WRENN NORTH CAROLINA
Director Environmental Qaallry
April 20, 2021
LETTER OF APPROVAL
Samaritan's Purse
Attention: Ronald E. Wilcox, Chief Operating Officer
PO Box 3000
Boone, NC 28607
RE: Project Name: Samaritan's Purse Inn
Acres Approved: 3.11
Project ID: WILKE-2021-010
County: Wilkes
City: North Wilkesboro
Address: White Pine St.
River Basin: Yadkin-PeeDee
Stream Classification: C
Submitted By: EMH&T
Date Received by LQS: April 14, 2021
Plan Type: New - Express
Dear Sir or Madam:
This office has reviewed the subject erosion and sedimentation control plan. We find the plan to
be acceptable and hereby issue this letter of Approval. This plan approval shall expire three (3)
years following the date of approval, if no land -disturbing activity has been undertaken, as is
required by Title 15A NCAC 4B .0129.
As of April 1, 2019, all new construction activities are required to complete and submit an
electronic Notice of Intent (eNOI) form requesting a Certificate of Coverage (COC) under the
NCG010000 Construction General Permit. After the form is reviewed and found to be complete,
you will receive a link with payment instructions for the $100 annual permit fee. After the fee is
received, you will receive the COC via email. You MUST obtain the COC prior to commencement
of any land disturbing activity. The eNOI form may be accessed at deq.nc.gov/NCG01. Please
direct questions about the eNOI form to Annette Lucas at [e-mail] or Paul
Clark at Paul,[e-mail]. If the owner/operator of this project changes in the future, the
new responsible party is required to apply for his/her own COC.
DE North Carolina Department of Environmental Qualtty I M910n OfEnffff. Mineral and lend Resaurces
Winston-SalemReglanal0(Hce 1 450Hanes Noll koadSuite 3001 Winston-Salem, North Carotlna27103
336.776.9800

Letter of Approval
Samaritan's Purse
April 20, 2021
Page 2 of 2
Title 15A NCAC 4B .0118(a) and the NCG01 permit require that the following documentation be
kept on file at the job site:
1. The approved E&SC plan as well as any approved deviation.
2. The NCG01 permit and the COC, once it is received.
3. Records of inspections made during the previous 12 months.
Also, this letter gives the notice required by G.S. 113A-61.1(a) of our right of periodic inspection
to ensure compliance with the approved plan.
North Carolina's Sedimentation Pollution Control Program is performance -oriented, requiring
protection of existing natural resources and adjoining properties. If, following the
commencement of this project, it is determined that the erosion and sedimentation control plan
is inadequate to meet the requirements of the Sedimentation Pollution Control Act of 1973
(North Carolina General Statute 113A-51 through 66), this office may require revisions to the
plan and implementation of the revisions to ensure compliance with the Act.
Acceptance and approval of this plan is conditioned upon your compliance with Federal and State
water quality laws, regulations, and rules. In addition, local city or county ordinances or rules
may also apply to this land -disturbing activity. This approval does not supersede any other
permit or approval.
Please note that this approval is based in part on the accuracy of the information provided in the
Financial Responsibility Form, which you provided. This permit allows for a land -disturbance,
as called for on the application plan, not to exceed the approved acres. Exceeding the acreage
will be a violation of this permit and would require a revised plan and additional application fee.
You are requested to file an amended form if there is any change in the information included on
the form. In addition, it would be helpful if you notify this office of the proposed starting date for
this project. Your cooperation is appreciated.
Sincerely,
Zachary Lentz, El
Assistant Regional Engineer
Land Quality Section
Enclosures: Certificate of Approval
NCG01 Fact Sheet
cc: Marcus Magers of EMH&T (via email)
WSRO file

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