NCC230044_FRO Submitted_20230110

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 r,f 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, plzfe N/A in the blank.)
Part A.
1 . Project Name Hawthuine Apartments at Ocean Isle Beach
2 Location of land -disturbing activity: County Brunswick City or Township_ Ocean Isle Beach
Highway/Street Ocean Isle Beach Rd SW Latltude(decimai degrees) 33.933521 Longltude(decimal degrees)-78.4481 19
3. Approximate date land -disturbing activity will commence: 12/15/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 15.12 AC
6. Amount of fee enclosed $ 1600 . 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.
rA
8
0
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Philip M. Payonk, Jr E-mail Address ppayonk@HRPLiving com
Phone: Office # [phone] Mobile #
Landowner(s) of Reccrd (attach accompanied page to list additional owners).
G and W Industrial Properties, LLC _ [phone]
Name Phone: Office # Mobile #
1205 Galleria Blvd 1205 Galleria Blvd
Current Mailing Address
Rock Hill Sc
City State
10. Deed Book No. 4592
Current Street Address
29730 Rock Hill
Zip City
SC 29730
State
Zip
Page No.., 1394 Provide a copy of the most current deed.

Part B.
i. 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)
Hawthorne Residential Acquisition, LLC ppayonk@HRPLiving com
Company Name E-mail Address
806 Green Valli Rd, Suite 311 806 Green Valley Rd, Suite 311
Current Mailing Address Current Street Address
Greensboro NC 27408 Greensboro NC
City State Zip City State
Phone: Office # [phone] Mobile #
27408
Zip
Note: If the Financially Responsib; ! ; arty 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 foam 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.
Philip M. Payonk, Jr.
Type or rint name
Signs ure
Manager
Title or Authority
Date
a Notary Public of the County of
State of North Carolina, hereby certify, that PI3/IZa appeared personally
before me this day and being duly sworn acknowledged that thdfabove form was executed by him/her.
Witness my hand and notarial seal
this 2& day of 20 7/Z.
t�Cota
My commission expires June 22, 2025