NCC230074_FRO Submitted_20230111

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 NIA in the blank.)
Part A.
1. Project Name Pinehurst Resort & Country Club - Aberdeen Golf
2. Location of land -disturbing activity: County Moore City or Township Aberdeen
Highway/Street N Hwy 5 Latitude(deamal debt....] 35.151 Longltude(decimal degrees) -79.456
3. Approximate date land -disturbing activity will commence: 12/15/22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Golf Course
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 200
6. Amount of fee enclosed: $ 20, 000 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 ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Bob Farren E-mail [e-mail]
Phone: Office # 910-235-8516 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Pinehurst Inc. 910-235-8409
Name
PO Box 4000
Current Mailing Address
Pinehurst NC 28374
Phone: Office # Mobile #
210 Beulah Hill Road
Current Street Address
Pinehurst NC 28374
City State Zip City
10. Deed Book No. 1541 Page No. 118
State
Zip
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).
Pinehurst, LLC
Company Name
PO Box 4000
Current Mailing Address
Pinehurst NC 28374
City State Zip
Phone: Office # 910-235-8409
dick. [e-mail]
E-mail Address
210 Beulah Hill Road
Current Street Address
Pinehurst NC 28374
City State Zip
Mobile #
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:
NA
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
(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:
NA
Name of Registered Agent
E-mail Address
Current Mailing Address Current Street Address
City
Phone., Office #
State 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.
I01l►,1
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.
Richard Higginbotham
Senior Vice President & CFO
Typ r print Title or Authority
// rox
Signature Date
-------L --L6 et,
-----------------------------------------------------------------------------------------
I, 6 1 1 i'a-, a Notary Public of the County of IN-) Oo e
State of North Carolina, hereby certify that card i appeared personally
before me this day and being duly sworn acknowledged that th ove form was executed by him/her.
Witness my hand and notarial seal, this lbt'day of K\1514Cben 2 , 202 Z
gA--L
Notary
A
My commission expires 10 4 o'20a3
O�lti
NotorV Public
Moore
County -
My Comm. Exp.
2 02-03-2023 Q
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��'�i 'y CARD 4%

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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:
Pinehurst Inc.
910-235-8409
Name
Phone: Office #
Mobile #
PO Box 4000
210 Beulah Hill Road
Current Mailing Address
Current Street Address
Pinehurst NC
28374
Pinehurst NC
28374
City State
Zip
City State
Zip
Deed Book No. 1541
118
Page No.
Provide a copy of the
most current deed.
Landowner 3 of Record:
PCC Realty, LLC
910-235-8409
Name
Phone: Office #
Mobile #
PO Box 4000
210 Beulah Hill Road
Current Mailing Address
Current Street Address
Pinehurst NC
28374
Pinehurst NC
28374
City State
Zip
City State
Zip
Deed Book No. 3843
Page No.
308 Provide the deed.
a copy of
most current
Landowner 4 of Record:
PCC Realty Corp
910-235-8409
Name
Phone: Office #
Mobile #
PO Box 4000
210 Beulah Hill Road
Current Mailing Address
Current Street Address
Pinehurst NC
28374
Pinehurst NC
28374
City State
Zip
City State
Zip
Deed Book No. 1616
Paoe No.
366 Provide a ronv of the most riirrPnt deed
Landowner 5 of Record:
PCC Realty Corp. 910-235-8409
Name Phone: Office # Mobile #
PO Box 4000 210 Beulah Hill Road
Current Mailing Address Current Street Address
Pinehurst NC 28374 Pinehurst NC 28374
City State Zip City State Zip
487 950
Deed Book No. Page No. Provide a copy of the most current deed.