NCC233757_FRO Submitted_20240110

. `.•
1805 West City Drive
P 252.621.5030
Till M O N S GROUP Unit E F 252.562.6974
Elizabeth City, NC 27909 www.timmons.com
August 29, 2023
Mr. Randall Jones, Jr., PE
NC Dept. of Environmental Quality
Division of Energy, Mineral and Land Resources
943 Washington Square Mall
Washington, NC 27889
RE: Erosion and Sediment Control Permit
Dollar General - Winfall
Timmons Project No. 41389.082
Dear Mr. Jones:
Enclosed for your review and approval, please find the following items:
1. The original and (2) copies of the Financial Responsibility Form.
2. Three (3)copies of the plans for the above referenced project.
3. Three (3)copies of the drainage narrative and appendix containing: Stormwater and Erosion
Control Calculations; Soil Data; Precipitation Data; a portion of the USGS quad map showing
project location; the FEMA FIRMette for the site; and the current deed and printouts from the
Secretary of State website for the owner and applicant corporations.
4. The original authorization letter from the property owner/seller and the adjacent property owner.
5. A check in the amount of$200.00 for the required fee.
If you have any questions or require any additional information, please do not hesitate to contact me at
[phone].
Sincerely,
Timmons Group
*v-ydo e/j1( . ` . ovykb
Kimberly D. Hamby, PE
Sr. Project Manager
cc: file
Glendon Forest Equity, LLC
ENGINEERING I DESIGN I TECHNOLOGY

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 NCG01 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 Dollar General - Winfall
'1f 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.PerqulmanS City or Township Winfall
Winfall Blvd 36.217171 -76.462831
Highway,Street Latitude(decimal degrees) Longltude(decimaldegrees)
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential, commercial, industrial, institutional, etc.):commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .69
6. Amount of fee enclosed: $200.00 . 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 ❑x Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name George T. Barnes, Jr. E-mail Address [e-mail]
Phone: Office# 919.459.2601 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Up For Rent, LLC 252.394.3115
Name Phone: Office# Mobile#
1142 Weeksville Road 1142 Weeksville Road
Current Mailing Address Current Street Address
Elizabeth City, NC 27909 Elizabeth City, NC 27909
City State Zip City State Zip
10. Deed Book No. 525 Page No.206
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).
Glandon Forest Equity, LLC [e-mail]
Company Name E-mail Address
3825 Barrett Drive, Suite 100 3825 Barrett Drive, Suite 100
Current Mailing Address Current Street Address
Raleigh, NC 27609-7221 Raleigh, NC 27609-7221
City State Zip City State Zip
Phone: Office#
919.459.2601 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:
Amy Biggers [e-mail]
Name of Registered Agent E-mail Address
3825 Barrett Drive, Suite 100 3825 Barrett Drive, Suite 100
Current Mailing Address Current Street Address
Raleigh, NC 27609-7221 Raleigh, NC 27609-7221
City State Zip City State Zip
Phone: Office#
919.459.2600 Mobile# [phone]
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.
George T. Barnes, Jr Manager
Type or print Title or
Authorityrit
Vi 0/
cn
Signature Dat
I, T.401A4A- Akitol4 , a Notary Public of the County of wale
State of North Carolina, hereby certify that 1.& 1° haat cif, 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 /0- day of 44/11444 , 20 �3
Nota 1(6111.1514.
otary Public M d�'y commission expires �' ' �v /b
= Wake County

ORIGINAL.DOCUMENT.PRINTED ON CHEMICALREACTIVE PAPER WITH MICROPRINTED BORDER.
le 17340
NORTH STATE BANK
GLANDON FOREST EQUITY, LLC RALEIGH,NC 27609
3825 BARRETT DRIVE,SUITE 100 66-1235/531
RALEIGH,NC 27609 8/11/2023 =
PAY TO ORDER OF E NCDEQ $ **200.00 8
Two Hundred and 00/1000******************************************* *******************
DOLLARS
Lf
NCDEQ N
coaf
yP V i f
eis,1i'Eio) '9F ,•`
MEMO AUTHORIZED SIGNATURE 641,,w1`\
Eroision Control permit- DG-Winfali
•ind'•1 ...SLy EEIy1Vj:�t•:fti:C•T:1l..,,.1:1�-i�-1�•71!,I , y __

GLANDON FOREST EQUITY,LLC 17340
NCDEQ 8/11/2023
Date Type Reference Original Amt. Balance Due Discount Payment
8/11/2023 Bill Winfall Erosion 200.00 200.00 200.00
Check Amount 200.00

August i5 , 2023
To Whom It May Concern.
As owner of PIN Number 5-D032-0183-W in Perquimans County, I hereby grant permission to
Glandon Forest Equity, LLC, to apply for and perform land disturbing activities on the referenced
property which is under contract for sale.
Sincerely,
Mrs. Lauren Spruill
Up For Rent, LLC
1142 Weeksville Road
Elizabeth City, NC 27909
�
(NOTARY) I, I -L C M as a notary public certify
under the pains and penalties of perjury that I witnessed the signature of
(-wit.() Sp -A 4.J I and the individual's identity was verified, on this
date i5th t , 20 _5 . My commission expires on
\C-Ct---(15CArV
51CLIC -
Cow,- -

August , 2023
To Whom It May Concern:
As owner of PIN Number 5-D032-0184-W in Perquimans County, I hereby grant permission to
Glandon Forest Equity, LLC, to apply for and perform minor land disturbing activities as
necessary to perform ditch cleanout in the property line ditch along the south side of my
property.
Sincerely,
I `J
Mr. James Michael Harrel
415 E. Main Street
Ahoskie, NC 27910
(NOTARY) I, a , as a notary public certify
under the pains and penalties of perjury that I witnessed the signature of
J rc_i 1 and the individual's identity was verified, on this
date A.-.��S k a 2 , 20 Ls . My commission expires on
1 - Zs
\\,\\ .3 0 NFS
=m z_
6FRTFOR� Go\