NCC241972_FRO Submitted_20240628

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: P75249 - NC 98 Tie-In at Averette Road
*If 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).
Is Project ARPA Funded ARPA Project Name ARPA Project#
No
2. Location of land-disturbing activity: County: Wake City or Township: Wake Forest
Highway/Street: Wait Avenue (NC-98) Latitude: 35.963000 Longitude:-78.459000
3. Approximate date land-disturbing activity will commence: 6/3/2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Other: Utility installation -
Gas pipeline Service
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.60
6. 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).
7. Has an erosion and sediment control plan been filed? No
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Robert Turnbull E-mail Address: [e-mail]
Phone: [phone] Mobile: [phone]
9. Landowner(s)of Record:
Landowner(s) of Record
Name Email Business Phone Mobile Phone
NCDOT Highway Division 5, District 1 919-733-3213
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
1575 Mail Service Raleigh NC 27699 1575 Mail Service Raleigh NC 27699
Center Center

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).
Primary Financially Responsible Party
Company Name Email Business Phone Mobile Phone
Public Service Company of North [e-mail] 704-810-3259
Carolina, Incorporated
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
800 Gaston Gastonia NC 28056 PO Box 1398 Gastonia NC 28053
Road
Additional Financially Responsible Parties
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:
Registered Agent Information
Name Email Business Phone Mobile Phone
CT Corporation System Attn: CT- 302-777-0204
Sherry McGinnes [e-mail]
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
160 Mine Raleigh NC 27615 160 Mine Lake Ct Raleigh NC 27615
Lake Ct Ste Ste 200
200
(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:
North Carolina Agent Information
Name Email Business Phone Mobile Phone
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
Engineering/Consulting Firm Information
Name Email Business Phone Mobile Phone
S&ME, Inc. [e-mail] 704-523-4726
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
2016 Ayrsley Charlotte NC 28273 2016 Ayrsley Charlotte NC 28273
Town Blvd. Suite Town Blvd. Suite
2A 2A

Additional Details
1. Stream Classification: C: Aquatic Life, Secondary Contact Recreation, Fresh water; HQW: High Quality
Waters; NSW: Nutrient Sensitive Waters; WS-II: Water Supply II
2. Was Express Review Requested: Yes
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.

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 P75249- NC 98 Tie-In at Averette Road
2. Location of land-disturbing activity: County Wake City or Township N/A
Wait Avenue (NC 98) 35°57'45.6"N 78°27'33.00"W
Highway/Street Latitude(decimai degrees) 35.963° LOngitUde(decimal degrees) -78.459°
3. Approximate date land-disturbing activity will commence:June 3,2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility Linear
5. Total acreage disturbed or uncoveradlincluding off-site borrow and waste areas): 2.60 Acres
Express: $750
Regular: $300
6. Amount of fee enclosed Total: $ 1050 . The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example: 8.10-acre application fee is$2,900). 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 Robert Turnbull E-mail Address [e-mail]
Phone: Office# N/A Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
NCDOT Highway Division 5, District 1 [phone] N/A
Name Phone: Office# Mobile#
1575 Mail Service Center N/A
Current Mailing Address Current Street Address
Raleigh NC 27699-1575 N/A
City State Zip City State Zip
NCDOT ROW N/A
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).
Public Service Company of North Carolina, Incorporated [e-mail]
Company Name E-mail Address
P.O. Box 1398 800 Gaston Road, Building A
Current Mailing Address Current Street Address
Gastonia NC 28053 Gastonia NC 28056-9486
City State Zip City State Zip
Phone: Office# 704 810 3259 Mobile# N/A
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(NCSOS ID#0519077)
Attn:Sherry McGinnes(Project ID#75249) [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Phone: Office#302-777-0204 Mobile#
Sherry McGinnes
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 N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
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.
Dominion Energy North Carolina
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation.
S&ME, Inc. [e-mail]
Engineering firm or other consultant E-mail Address
Joshua M.Bell, P.E. 704-523-4726 N/A
Individual contact person (type or print) Phone: Office# Mobile#
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.
Andrew Moore, P.E. Director- Engineering &Construction
Type or print name Title o Authority
5/2-14 /2_024—
Signature Date
I, 0,15141%e( ``- <AAA/a_(cac), a Notary Public of the County of C CS 1p-Th
State of North Carolina, hereby certify that C30Yf=- 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 IkACUI , 20 2-4-
-a_ _At r
CYNTHIA M. ALVARADO
NOTARY PUBLIC Nota
Gaston County
North Carolina
5 > My commission expires LC�I
Commission Expires 10'�}2