NCC222112_FRO Submitted_20220607

FINANCIAL RESPONSIBILITY/OWNERSHIP 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 N/A in the blank.)
Part A.
1. Project Name Orchard Hill Retreat
2. Location of land -disturbing activity: CountyAVery City or Township Banner Elk
Highway/Street TBD Orchard Lane Latitude(decimal degrees) 36-148201 Longitude(decimal degrees)-81.858512
3
4
5
Approximate date land -disturbing activity will commence: June 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Multi-Famil
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.56 acres
6. Amount of fee enclosed $400+1,000= $1,400 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, afterwhich 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.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑ No 2
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Shaw Kuester E-mail Address [e-mail]
Phone: Office # 903 - 5 7? - -1-12Y Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Orchard Hill - BE, LLC 704-996-9996
Name Phone: Office #
127 Ben Casey Drive - Suite 103
Current Mailing Address
Fort Mill SC 29708
City
704-996-9996
Mobile #
127 Ben Casey Drive - Suite 103
Current Street Address
Fort Mill SC 29708
State Zip City
State
911
10. Deed Book No. 572 Page No. 2432 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 company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Orchard Hill - BE, LLC [e-mail]
Company Name E-mail Address
127 Ben Casey Drive - Suite 10.3 127 Ben Casey Drive - Suite 103
Current Mailing Address Current Street Address
Fort Mill SC 29708 Fort Mill SC 29708
City State Zip City State Zip
Phone: Office # 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:
Moffit & Moffit, PLLC
Name of Registered Agent E-mail Address
PO Box 233 - DTS 833 State Farm Road
Current Mailing Address Current Street Address
Boone NC 28607 Boone NC 28607
City State Zip City State Zip
Phone: Office # 828-278-9123 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 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)
(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:
BREC, PA [e-mail]
Engineering firm or other consultant E-mail Address
Justin Church, PE 336-844-4088
Individual contact person (type or print) Phone: Office #
828-773-6543
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.
Shaw Kuester
Type or na
Signature
Officer
Title or Authority
jr, - z — Lz.
Date
I, 11 � i {/Yl , a Notary Public of the County of
t►�a-
State of Natfth-carol a, hereby certify that U� appeared personally
before me this day and being duly sworn ackn wledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of NLkm , 20
Jacqueline M. Broom
NOTARY PUBLIC
State of South Carolina
My Comm6ftWn Expires 12/3/2030