NCC230111_FRO Submitted_20230113

Check if this project is ARPA-funded '_1
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 NameHawthorne at The Pointe Phase II
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI)
2. Location of land -disturbing activity: County New Hanover City or TownshipWilmington
ilmington
Highway/Street Echo Farms Blvd Latltude(decimaidegrees) 34.1661 Long ltude(decimaldegrees) -77,9197
3. Approximate date land -disturbing activity will commence: 1 /12/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.6
6. Amount of fee enclosed: $ 1 400.00 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 K Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NamePhilip M. Payonk E-mail Address [e-mail]
Phone: office # 3362759511 Mobile # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
HM Woodlands Phase II,LLC 3362759511 N/A
Name
806 Green Valley Rd suite 311
Current Mailing Address
Greensboro, NC 27408
Phone: Office # Mobile #
806 Green Valley Rd suite 311
Current Street Address
Greensboro, NC 27408
City State Zip City
10. Deed Book No.6476 Page No.1623
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).
HM Woodlands Phase II,LLC
Company Name
806 Green Valley Rd suite 311
Current Mailing Address
Greensboro, NC 27408
City State Zip
Phone: office # 3362759511
[e-mail]
E-mail Address
806 Green Valley Rd suite 311
Current Street Address
Greensboro, NC 27408
City State Zip
Mobile # NIA
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:
Philip M. Payonk
Name of Registered Agent
806 Green Valley Rd suite 311
Current Mailing Address
Greensboro, NC 27408
City
State
[e-mail]
E-mail Address
806 Green Valley Rd suite 311
Current Street Address
Greensboro, NC 27408
Zip City
Phone: office # 3362759511 Mobile # NIA
NIA
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:
NIA
Name of Registered Agent
NIA
Current Mailing Address
NIA
City
Phone: office # NIA
NIA
NIA
E-mail Address
NIA
Current Street Address
NIA
State Zip City
Mobile # NIA
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.
Iwhil
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.
Philip M. Payonkl
Type or print name
Signature
Manager
Title or Authority
Date
I, '�hal at WKN 11-1OYAtllln � , a Notary Public of the County of Cx1 'I (ib'rd
State of North Carolina, hereby certify that '�� , '', 01 il` u ` appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by himlher.
Witness my hand and notarial seal, this �i day of CGiq ka,,YV 20
,
` t,EWHfsoN". Notar
y
NOTARY
IIC My commission expires ►.} �I6i' bI ,-� 20 Z,)'7
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My Comm. Exp,
Nov 20, 2027
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