NCC224141_FRO Submitted_20221219

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 Cape Fear River Campground
2. Location of land -disturbing activity: County Lee City or Township Deep River
Highway/Street Lower River Road Latltude(decimal degrees) 35.566 N Lorlgltude(decimal degrees) 79.055
VV
3. Approximate date land -disturbing activity will commence: 09/01/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 87.2 Acres
6. Amount of fee enclosed: $ 8,800 . 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 ;KL No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Vaughn King E-mail Address vaughnkin([e-mail]
Phone: Office # Mobile # [phone]
M
Landowner(s) of Record (attach accompanied page to list additional owners):
Cape Fear River Campground; LLC _
Name Phone: Office #
341 Kilmayne Drive, Suite 201
Current Mailing Address
Cary NC 27511
City State
Zip
[phone]
Mobile #
341 Kilmayne [give; Suite 201
Current Street Address
Cary NIC 27511
City State Zip
10. Deed Book No. 1673 Page No. 168 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).
Cape Fear River Campground LLC vaughnking5-@,,gmail.uom
Company Name E-mail Address
341 Kilmayne give; Suite 201 341 Kilrnayne Drive, Suite 201
Current Mailing Address Current Street Address
Cary NC 27511 Cary IyC 27511
City State Zip City
Phone: Office # [phone] Mobile #
State Zip
[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
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.
Type or pript ame
a
Signaturb,
Title or Authority
Date
I, Arnor'AO' Qj\aynm a Notary Public of the County of
State of North Carolina, hereby certify that �IGv.o�`nr �� n� 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 1\ day of S`-\
Notary Public
Lee =
county
•���"TH'C'AR`\`\��
Notary
My commission expires
20 'Ll

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:
Cape Fear River Campground LLC
[phone]
Name
Phone: Office # Mobile #
341 Kilmayne Drive Suite 201
341 Kilmayne Drive Suite 201
Current Mailing Address
Current Street Address
Cary NC
27511
Cary NC 27511
City State
Zip
City State Zip
Deed Book No. ?663
Page No.
17 Provide a copy of the most current deed.
Landowner 3 of Record:
Chatham Capital Group LLC
[phone]
Name
Phone: Office # Mobile #
1064 N Lakeside Drive
1064 N Lakeside Drive
Current Mailing Address
Current Street Address
Smithfield NC
27577
Smithfield NIC 27577
City State
Zip
City State Zip
Deed Book No. 1658
Page No.
456 Provide a copy of the most current deed.
Landowner 4 of Record:
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.
Landowner 5 of Record.
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.

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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #