NCC222344_FRO Submitted_20220701

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 NameWellers Knoll Subdivision
2. Location of land -disturbing activity: County Harnett City or Township Upper Little River
SR 1229 (McDougald Rd) N35.396411 W78.8905743
Highway/Street LatltUde(decimaldegrees) Long ltude(decimaldegrees)
3. Approximate date land -disturbing activity will commence: May 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14.00
6. Amount of fee enclosed 3400.00 . 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, 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameBraxton E-mail Address
Braxton Montague [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Weller Developers, LLC [phone]
Name Phone: Office # Mobile #
10305 Penny Road 10305 Penny Road
Current Mailing Address Current Street Address
_Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
10. Deed Book No. 4090 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 company is 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).
Weller Developers, LLC
Company Name
10305 Penny Road
Current Mailing Address
Raleigh, NC 27606
[e-mail]
E-mail Address
10305 Penny Road
Current Street Address
Raleigh NC 27606
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:
Sherri Montague [e-mail]
Name of Registered Agent
10305 Penny Road
Current Mailing Address
Raleigh NC 27606
E-mail Address
10305 Penny Road
Current Street Address
Raleigh NC 27606
City State Zip City
Phone: Office #
Sherri Montague or Braxton Montague
State Zip
Mobile # [phone]
Name of Individual to Contact (if Registered Agent is a company)
Weller Developers, LLC
(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:
Carolina Land Development Group, Inc.
Engineering firm or other consultant
Spencer B. Terry III, P.E.
Individual contact person (type or print)
[e-mail]
E-mail Address
[phone]
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.
Sherri Montague
Registered Agent
Type or print name Tine or Authority
4/15/22
Signature Date
-----------------------------------------------------------------------------------------
I Ellen M Haynes _,a Notary Public of the County of Wake
State of North Carolina, hereby certify that Sherri Montague 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
Ellen M. Haynes
NOTARY PUBLIC
County
North Carolina
My Comm,as'on Exp,res June 11. 2023
15 day of April 2022
-m .
Notary
My commission expires J e,