NCC233288_FRO Submitted_20231103

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 Mountain Island Earth Dam Embankment Seismic Stability Improvements (ESSI) Project
2. Location of land-disturbing activity: County Gaston City or Township Gastonia
Mountain Island Road 35°19'58.09"N 80°59'30.32"W
Highway/Street Latitude(decimaidegrees)35.3328 Longitude(decimaidegrees)80.9912
3. Approximate date land-disturbing activity will commence: June 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Hydro Dam
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 43.40
6. Amount of fee enclosed: $ y ,L1i"J . The appli.c.ation 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 E Enclosed 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Gretchen Schroeder E-mail Address [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Duke Energy Corporation 980-373-8681
Name Phone: Office# Mobile#
422 South Church St. Same as Mailing Address
Current Mailing Address Current Street Address
NC 28242 0900
City State Zip City State Zip
10. Deed Book No. 22 Page No. 0238 Provide a copy of the most current deed.
Parcel 2 Parcel 4
Duke Energy Corporation Duke Energy Corporation
Phone:[phone] Phone:[phone]
422 S Church Street, Charlotte NC 28242-900 422 S Church Street, Charlotte NC 28242-900
Deed Book No. 2286 Page No. 71 Deed Book No. 3192 Page No. 0225
Parcel 3
Duke Energy Corporation
Phone:[phone]
422 S Church Street, Charlotte NC 28242-900
Deed Book No. 2286 Page No. 71

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).
Duke Energy Carolinas, LLC [e-mail]
Company Name E-mail Address
526 South Church Street, EC II 7th Floor Same as Mailing Address
Current Mailing Address Current Street Address
Charlotte NC 28202
City State Zip City State Zip
Phone: Office# Same as Mobile# Mobile# [phone]
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:
CT Corporation System [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct Ste 200 Same as Mailing Address
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City State Zip
Phone: Office# 919-546-7111 Mobile#
John Weber
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:
N/A
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.
Gretchen Schroeder Senior Project Manager
Type or print name Title or Authority
SAVO 0d C//31 )NCYaS
gnature Date
I, Ka.. S 4-1A trvvut:-. , a Notary Public of the County of L(J -Z
State of North Carolina, hereby certify that(0�Z ►-Ghr � S C h✓ Pd.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 a- tvn.to-c.- , 20 2D
KATHRYN SMOTHERMON
NOTARY PUBLIC Nota
WAKE COUNTY,N.C.
IItYCOMMISSION EXPIRES 10-27-2027.
My commission expires /00-1-(�0;�

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Duke Energy Corporation 980-373-8681
Name Phone: Office# Mobile#
422 S Church St, Charlotte, NC 28242-900 Same as Mailing Address
Current Mailing Address Current Street Address
Charlotte NC 28242-900
City State Zip City State Zip
Deed Book No. 2286 Page No. 71 Provide a copy of the most current deed.
Landowner 3 of Record:
Duke Energy Corporation 980-373-8681
Name Phone: Office# Mobile#
422 S Church St, Charlotte, NC 28242-900 Same as Mailing Address
Current Mailing Address Current Street Address
Charlotte NC 28242-900
City State Zip City State Zip
Deed Book No. 2286 Page No. 71 Provide a copy of the most current deed.
Landowner 4 of Record:
Duke Energy Corporation 980-373-8681
Name Phone: Office# Mobile#
422 S Church St, Charlotte, NC 28242-900 Same as Mailing Address
Current Mailing Address Current Street Address
Charlotte NC 28242-900
City State Zip City State Zip
Deed Book No. 3192 Page No. 0225 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.