NCC223156_FRO Submitted_20220929

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 Waynesville Inn & Golf Club - Farmers Branch
2. Location of land -disturbing activity: County Haywood City or Township Waynesville
Highway/Street County Club Drive Latltude(decimaldegrees)
35.471 Long itude(decimal degrees) -82.998
3. Approximate date land -disturbing activity will commence: 8/29/22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.24 Ac
6. Amount of fee enclosed: $ 200.00 . 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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brandon Graham E-mail Address [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
WGC Hospitality LLC 843.799.2306
Name Phone: Office # Mobile #
1943 Hoffmeyer Rd, Ste C
Current Mailing Address Current Street Address
Florence SC 29501
City State Zip City State Zip
10. Deed Book No. 1027 Page No. 2044 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).
Encore -Asheville, LLC
Company Name
411 West Pope Street
[e-mail]
E-mail Address
Current Mailing Address Current Street Address
Dunn NC 28334
City State
Phone: Office # 843.799.2306
Zip City
Mobile #
State
Zip
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:
Gale Tart
Name of Registered Agent
411 West Pope Street
Current Mailing Address
Dunn NC 28334
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
(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
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.
David Tart
Type--�r��i+�t me
r
Si nature
Manager
Title or Authority
i /
Date
I,DQY]leiIe, G600[e -,a Notary Public of the County of arl s-tDr
State of North Carolina, hereby certify that DaViol -FoL " i"' 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 1c� )*%day of , 20 2-2-
Notary
Seal l
My commission expires 110-7 f 2Z23

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:
CG & DG Enterprises LLC
Name Phone: Office # Mobile #
142 Country Club Drive
Current Mailing Address Current Street Address
Waynesville NC 28786
City State Zip City State Zip
Deed Book No. 799 Page No. 163 Provide a copy of the most current deed.
Landowner 3 of Record:
Jacob A. and Carla L. Youse
Name Phone: Office # Mobile #
116 Country Club Drive
Current Mailing Address Current Street Address
Waynesville NC 28786
City State Zip City State Zip
Deed Book No. 899 Page No. 2073 Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Current Mailing Address
City
Deed Book No._
Landowner 5 of Record:
Phone: Office # Mobile #
Current Street Address
State Zip City
Page No.
State Zip
Provide a copy of the most current deed.
Name Phone: Office # Mobile #
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.