NCC232919_FRO Submitted_20230927

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 N/A in the blank.)
Part A.
1. Project Name: Water Facilities, Contract 13,0—Distribution System Improvements Phase 2
2. Location of land-disturbing activity: County Scotland City or Township Laurinburq
Highway/Street: Johns St., Pine St., Vance St., 1s1 St., Caledonia Rd.
Latitude{decimal degrees 34.768273° Longitude(decimal degrees) -79.460165°
3. Approximate date land-disturbing activity will commence: March 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): N/A
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):_10.0
acres
6. Amount of fee enclosed: $ 1,000 . 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 CI
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Charles D. Nichols, Ill, City of Laurinburq E-mail Address cnicholsalaurinburq.orq
Phone: Office# 910.276.8324 Mobile#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
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)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 Laurinburg [e-mail]
Company Name E-mail Address
Post Office Box 249 303 West Church Street
Current Mailing Address Current Street Address
Laurinburg NC 28353 Laurinburg NC 28352
City State Zip City State Zip
Phone: Office# 910.276.8324 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)

(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.
Charles D. Nichols, III City Manager
Type 99p rint n Title or Authority
, i r - 3 -22
ignature Date
I, t flq.eka H H . T j tor , a Notary Public of the County of SCI)+10 C1
State of North Carolina, hereby certify that k2f(CS D- NiGhoISJ a
C,r 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 3' day of itLAg , 20 22
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owitisi . t4- . (et
.•��0A H. Tq 1//, Notary
7- 2;•�O-pAR��.7' My commission expires 0( • . 2 23
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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 1 of Record:
Westminster Presbyterian Church Mission, Inc.
Name Phone: Office# Mobile#
130 Edinburgh Street, Suite 208 Johns Road
Current Mailing Address Current Street Address
Cary NC 27511 Laurinburg NC 28353
City State Zip City State Zip
Deed Book No. 1362 Page No. 94 Provide a copy of the most current deed.
Landowner 2 of Record:
Scotland County Housing Authority
Name Phone: Office# Mobile#
P 0 BOX 1437 STEWARTSVILLE ROAD
Current Mailing Address Current Street Address
Laurinburg NC 28353 Laurinburg NC 28353
City State Zip City State Zip
Deed Book No. 1 125 Page No. 108 Provide a copy of the most current deed.
Landowner 3 of Record:
George Hatchell, Jr.
Name Phone: Office# Mobile#
502 E VANCE ST 502 E VANCE ST
Current Mailing Address Current Street Address
Laurinburg NC 28352 Laurinburg NC 28352
City State Zip City State Zip
Deed Book No. 1 125 Page No. 1 08 Provide a copy of the most current deed.
Landowner 4 of Record:
Marilyn Frances Still
Name Phone: Office# Mobile#
900 WAYCROSS ST 435 E COVINGTON STREET
Current Mailing Address Current Street Address
Laurinburg NC 28352 Laurinburg NC 28352
City State Zip City State Zip
Deed Book No. 1125 Page No. 1 08 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 5 of Record:
Passgo Investment Group, LLC.
Name Phone: Office# Mobile#
PO BOX 2128 501 E COVINGTON ST
Current Mailing Address Current Street Address
Laurinburg NC 28352 Laurinburg NC 28352
City State Zip City State Zip
Deed Book No. 1214 Page No. 123 Provide a copy of the most current deed.
Landowner 6 of Record:
William Hunt
Name Phone: Office# Mobile#
1825 MIDLAND RD FIRST STREET
Current Mailing Address Current Street Address
SOUTHERN PINES, NC 28387 Laurinburg NC 28352
City State Zip City State Zip
Deed Book No. 1 166 Page No. 133 Provide a copy of the most current deed.
Landowner 7 of Record:
Victor T. McVea Jr.
Name Phone: Office# Mobile#
20401 94TH AVE E 1 CALEDONIA ROAD
Current Mailing Address Current Street Address
GRAHAM, WA 98338 Laurinburg NC 28352
City State Zip City State Zip
Deed Book No. 1645 Page No. 257 Provide a copy of the most current deed.
Landowner 8 of Record:
Edwin and Mary Purcell
Name Phone: Office# Mobile#
105 A CALEDONIA ROAD 102 BARRUS AVE
Current Mailing Address Current Street Address
Laurinburg NC 28352 Clinton NC 28328
City State Zip City State Zip
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 9 of Record:
Scotland County and City of Laurinburg
Name Phone: Office# Mobile#
105 CALEDONIA ROAD PO BOX 488
Current Mailing Address Current Street Address
Laurinburg NC 28352 Laurinburg NC 28352
City State Zip City State Zip
Deed Book No. 1679 Page No. 1 59 Provide a copy of the most current deed.
Landowner 10 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 11 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 12 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.