NCC231389_FRO Submitted_20230511

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Wynfall Subdivision Phase One
1. Project Name y _
2. Location of land-disturbing activity: County Davidson _City or Township Lexington
Highway/Street Hinkle Lane Latitude 35d54'30" Longitude 80d14'18"___
3. Approximate date land-disturbing activity will commence:May 1 , 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.):residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):6.77 AC
6. Amount of fee enclosed: $455__ . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is$585).
7. Has an erosion and sediment control plan been filed? Yes _No _Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Tim Kennerly E-mail Address [e-mail]
Telephone[phone] Cell # [phone] Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Buel B. Barker, Jr. [phone] [phone]
Name Telephone Fax Number
3632 Friedberg Church Rd 3632 Friedberg Church Rd
Current Mailing Address Current Street Address
Winston-Salem, NC 27127 Winston-Salem, NC 27127
City State Zip City State Zip
10. Deed Book No. Page No.__ Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager maybe listed as the financially responsible party.
Buel B. Barker, Jr.
Name E-mail Address
3632 Friedberg Church Rd 3632 Friedberg Church Rd
Current Mailing Address Current Street Address
Winston-Salem, NC 27127 Winston-Salem, NC 27127
City State Zip City State Zip
Telephone[phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, 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
Telephone Fax Number
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Buel B. Barker, Jr.
Type or print name Title or Authorit
3 o?6o o?/
Sig tune Date
Z i tul1 e -1 Car 14 are , a Notary Public of the County of f U(y
State of North Carolina, hereby certify that BU..e-[ B • Bar k e j SR- appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. yam
Witness my hand and notarial seal, this a(O day of -I dA- , 20 a- 1
fact,tee,
DIANE D. CARLTON Notary
SeaNOTARY PUBLIC
Forsyth County, N.C. My commission expires I,-)- a0 a a.
My Commission Expires Dec 14,2022.