NCC233091_FRO Submitted_20231016

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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 The Cottages at Wingate Phase 2
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County Union City or Township Wingate
Highway/Street Maye Street Latitude(decimal degrees)34.98716 Longltude(decimaldegrees) -80.469783
3. Approximate date land-disturbing activity will commence: 10/1/23
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 30.37
6. Amount of fee enclosed: $$3,100 . 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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name H&H Constructors of Fayetteville, LLC E-mail Address [e-mail]
Phone: Office# 434.426.8049 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Shelby Cattle Farm, LLC 704-882-1700
Name Phone: Office# Mobile#
231 Post Office Drive STE B-8 231 Post Office Drive STE B-8
Current Mailing Address Current Street Address
Indian Trail, NC 28079 Indian Trail, NC 28079
City State Zip City State Zip
Page No. 0428
10. Deed Book No. 8389 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:
DFC Wingate, LLC
Name Phone: Office# Mobile#
13000 Sawgrass Village Circle, Building 5, Ste 24 13000 Sawgrass Village Circle, Building 5, Ste 24
Current Mailing Address Current Street Address
Point Vedra Beach, FL 32082 Point Vedra Beach, FL 32082
City State Zip City State Zip
Deed Book No.8568 Page No. 0190 Provide a copy of the most current deed.
Landowner 3 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 4 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 5 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.

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).
H&H Constructors of Fayetteville, LLC [e-mail]
Company Name E-mail Address
201 McCullough Drive, STE 160 201 McCullough Drive, STE 160
Current Mailing Address Current Street Address
Charlotte, NC 28262 Charlotte, NC 28262
City State Zip City State Zip
Phone: Office# 434.426,8049 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:
Jay C Lewis, II
Name of Registered Agent E-mail Address
13000 Sawgrass Village Circle, Building 5, Ste 24 8601 Six Forks Rd
Current Mailing Address Current Street Address
Raleigh NC, 27615 Point Vedra Beach, FL 32082
City State Zip City State Zip
Phone: Office# 910-800-1350 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.
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Type or printnarne Title or Authority
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Signatu Date
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I, 3:3 en.t , a Notary Public of the County of m?. sr.,e�4._,-
State of North Carolina, hereby certify that erc (R+BL3S-re=t 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 2- day of Au6„s1-— , 20 Z.3
otary
Seal
My commission es 7/12/7apS
JOHN D. OSINGA
OWNOTARY PUBLIC
: Mecklenburg County
North Carolina
My Commission Expires 07/12/2025