NCC241819_FRO Submitted_20240625

FINANCIAL RESPONSIBILITY/OWNERSHIP F RM
SEDIMENTATION POLLUTION CONTROL CT
No person may initiate any land-disturbing activity on one or more acres as coy red by the Act before this form
and an acceptable erosion and sedimentation control plan have been compl ted 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 r the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Briarwood Bluff Phase II
2. Location of land-disturbing activity: County Harnett City or Township Barbeque
Highway/Street Pine Vista Way Latitude decimal degrees)35.357048 -79.043206
( g ) LOngltude(decimal degrees)
3. Approximate date land-disturbing activity will commence:July 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 8.75
6. Amount of fee enclosed: $900 . 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 Dustin Blackwell E-mail Address [e-mail]
Phone: Office# 910-433-0888 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
BLW Holdings, LLC 910-433-0888 919-606-4696
Name Phone: Office# Mobile#
350 Wagoner Drive 350 Wagoner Drive
Current Mailing Address Current Street Address
Fayetteville, NC 28303 Fayetteville, NC 28303
City State Zip City State Zip
10. Deed Book No.4230 Page No. 1596-1598 Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activi (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole pr rietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially respo sible party(ies).
BLW Holdings, LLC [e-mail]
Company Name E-mail Address
350 Wagoner Drive 350 Wagoner Drive
Current Mailing Address Current Street Address
Fayetteville, NC 28303 Fayetteville, N 28303
City State Zip City State Zip
Phone: Office# 910-433-0888 Mobile# [phone]
Note: If the Financially Responsible Party is not the owner of the land to be •isturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a 'raft 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 •n 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 as-umed 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 nd 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, part er, 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 pro ided herein.
Dustin Blackwell Officer
Typ or ' me Title or Authorit
a3/)if
Signature Date
I, NaAl Ina() , a NotaryPublic of the CoL nt of CZALW IptilJ
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State of North Carolina, hereby certify that `�"4"'1‘) ►4c6� I 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 ,2-3 day of 14-1 iL , 20 �
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