NCC222758_FRO Submitted_20220816

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 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_ Myrtle Manor
2. Location of land -disturbing activity: County Harnett City or Township Angier
Highway/Street SR 1509 Latitude (decimal degrees) 35.485432 Longltude(decimal degrees)-78.748876
3. Approximate date land -disturbing activity will commence: ,June/July 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 30.1 aC.
6. Amount of fee enclosed: $ 3,100.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $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:
Name Dennis Peacock E-mail Address [e-mail]
graywolfhomes.com
Phone: Office # 919-934-7788 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
KBNK Holdings 919-824-0252
Name Phone: Office # Mobile #
535 Hickorywood Blvd.
Current Mailing Address Current Street Address
Cary NC 27519
City State Zip City State Zip
10. Deed Book No. 2441 Page No. 803-805 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).
Gray Wolf Development, LLC [e-mail]
Company Name E-mail Address
10920 Cleveland Rd Suite 100
Current Mailing Address Current Street Address
Garner NC 27529 _
City State Zip City
Phone: Office # 919-934-7788 Mobile #
State
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:
Gray Wolf Development, LLC
Name of Registered Agent
10920 Cleveland Road Ste 100
Current Mailing Address
Garner NC 27529
City
State
E-mail Address
Current Street Address
Zip City
Phone: Office # 919-934-7788 Mobile #
Ben Mathis
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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
E-mail 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.
N/A
Company DBA Name
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.
Ben Mathis Chief Operating Officer
Type int name
i
ignature
Title or Authority
April 4, 2022
Date
r1;\,r1 iv\ Lc c-q Gca o. , a Notary Public of the County of o\ s �Z�.Q
` State of North Carolina, hereby certify that 1`nn
�V-) ,m c��'1i� c 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 -�tday of 20 ZC
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My commission expires v , 7,Q - &0 23

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name
Current Mailing Address
Phone: Office #
Current Street Address
City State Zip City
Deed Book No. Page No.
Mobile #
State Zip
Provide a copy of the most current deed.
Landowner 3 of Record:
Phone: Office # Mobile #
Name
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Phone: Office # Mobile #
Name
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Phone: Office # Mobile #
Name
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address
Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #