The URL can be used to link to this page

Home My WebLink AboutNCC231190_FRO Submitted_20230428 Check if this project is ARPA-funded ❑ 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 NCGO1 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 Name Knox& Bethel Church Road Waterline Improvements *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 Guilford City or Township Greensboro Highway/Street & Bethel Church Rd Latitude(decimal degrees)36.08836 Longitude(decimai degrees)-79.63950 3. Approximate date land-disturbing activity will commence: September 1, 2023 Utility 4. Purpose of development(residential, commercial, industrial, institutional, etc.): 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 5.4 6. Amount of fee enclosed: $ 600 . 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 ❑x No D 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Shane Messer Email Address shane.messer@greensboro-nc.gov Phone: Office# 336-574 3550 Mobile# 9. Landowner(s)of Record (attach accompanied page to list additional owners): Twin Oaks Church Inc. Name Phone: Office# Mobile# 5935 Burlington Road 5935 Burlington Road Current Mailing Address Current Street Address Greensboro NC 27249 Greensboro NC 27249 City State Zip City State Zip 6677 20 10. Deed Book No. Page No. 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). City of Greensboro michael.borchers@greensboro-nc.gov Company Name E-mail Address 2602 S. Elm-Eugene Street Current Mailing Address Current Street Address Greensboro NC 27406 City State Zip City State Zip Phone: Office# 336-373-2055 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: 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) 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: Michelle Reese Morris Name Phone: Office# Mobile# 334 Knox Rd. 320 Knox Rd. Current Mailing Address Current Street Address Greensboro NC 27249 Greensboro NC 27249 City State Zip City State Zip 4441 1181 Deed Book No. Page No. Provide a copy of the most current deed. Landowner 3 of Record: Brian Nettles Name Phone: Office# Mobile# 500 Knox Road 500 Knox Road Current Mailing Address Current Street Address Greensboro NC 27249 Greensboro NC 27249 City State Zip City State Zip 5768 1680 Deed Book No. Page No. Provide a copy of the most current deed. Landowner 4 of Record: Wayne & Diane Wilson Name Phone: Office# Mobile# 406 Knox Road 406 Knox Road Current Mailing Address Current Street Address Greensboro NC 27249 Greensboro NC 27249 City State Zip City State Zip Deed Book No. 6241 Page No. 2222 Provide a copy of the most current deed. Landowner 5 of Record: Edward & Beverly Rich Name Phone: Office# Mobile# 6041 Bethel Church Road 6041 Bethel Church Road Current Mailing Address Current Street Address Greensboro NC 27249 Greensboro NC 27249 City State Zip City State Zip 6179 1230 Deed Book No. Page No. Provide a copy of the most current deed. 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: Elisabeth & Matthew Allen Name Phone: Office# Mobile# 6202 Bethel Church Rd 6202 Bethel Church Rd Current Mailing Address Current Street Address Greensboro NC 27249 Greensboro NC 27249 City State Zip City State Zip Deed Book No. 8158 Page No. 762 Provide a copy of the most current deed. Landowner 3 of Record: James Hires Jr.,Angelette Coffey Name Phone: Office# Mobile# 6119 Bethel Church Rd. 6119 Bethel Church Rd. Current Mailing Address Current Street Address Greensboro NC 27249 Greensboro NC 27249 City State Zip City State Zip Deed Book No. 6176 Page No. 1230 Provide a copy of the most current deed. Landowner 4 of Record: Luanna Goodall-Rorie Name Phone: Office# Mobile# 4294 Harbor Ridge Dr. 400 Knox Rd. Current Mailing Address Current Street Address Greensboro NC 27406 Greensboro NC 27249 City State Zip City State Zip Deed Book No. 7958 Page No. 1087 Provide a copy of the most current deed. Landowner 5 of Record: Bethel Presbyterian Church of McLeansville Name Phone: Office# Mobile# 300 Knox Rd 300 Knox Rd. Current Mailing Address Current Street Address Greensboro NC 27249 Greensboro NC 27249 City State Zip City State Zip 2735 868 Deed Book No. Page No. Provide a copy of the most current deed. 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: William &Sandra Judy Name Phone: Office# Mobile# 6129 Bethel Church Rd 6129 Bethel Church Rd Current Mailing Address Current Street Address Greensboro NC 27249 Greensboro NC 27249 City State Zip City State Zip 7989 1100 Deed Book No. Page No. Provide a copy of the most current deed. Landowner 3 of Record: Guilford County Board of Education Name Phone: Office# Mobile# 712 N Eugene St 415 Peeden Dr Current Mailing Address Current Street Address Greensboro NC 27401 Greensboro NC 27249 City State Zip City State Zip 2568 569 Deed Book No. Page No. Provide a copy of the most current deed. Landowner 4 of Record: Winfield & Bobbye Hunter(Trustee) Name Phone: Office# Mobile# 204 Barcladine Ct 6146 Bethel Church Rd Current Mailing Address Current Street Address , Cary NC 27511 Greensboro NC 479 City State Zip City State 'Zip PtiA 8248 2390 Deed Book No. Page No. Provide a cey o?fhe mosf currentdeed. ;$ a Landowner 5 of Record: Jerry Nix(Trustee) Name Phone: Office# Mobile# PO Box 101 6188 Bethel Church Rd Current Mailing Address Current Street Address Whitsett NC 27377 Greensboro NC 27249 City State Zip City State Zip 7894 3049 Deed Book No. Page No. Provide a copy of the most current deed. (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. Michael Borchers Director of Water Resources Ty e or pr. t nam Title or Authority Sign ture Date I73: ` °t Ai , a Notary Public of the County of r rl cati State of North Carolina, hereby certify that e Q ( eot LI ChetS 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 day of ettf , 20 441110. Notary Seal 13 My commission expires u t b ®080 Q M®®®o° 4. NOTARY Corm.Ny Ex Aptd13,2J ®�,, PUBLIC '