NCC241881_FRO Submitted_20240709

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 NCG01 permit, before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Lana
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 Thales Academy @ Brunswick Forest
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Projec
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through th
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Brunswick City or Township Leland
Highway/Street Brunswick Village Blvd. Latltude(decimaI degrees) 34.190390 Longitude(decimal degrees)-78.063200
3. Approximate date land-disturbing activity will commence: Summer 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial Sites
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 12.84 Acres
6. Amount of fee enclosed: $ 1300 . 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 0 Enclosed ❑ No E
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Robert Corlett Robert.Corlett Ca tiveaire.com
Name E-mail Address @ p
Phone: Office# 919.427.1646 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Funston Land&Timber,LLC. [phone]
Name Phone: Office# Mobile#
1007 Evangeline Drive 1007 Evangeline Drive
Current Mailing Address Current Street Address
Leland, NC 28451 Leland, NC 28451
City State Zip City State Zip
10. Deed Book No. 02407 Page No. 1147 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 lis
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).
Thales Academy [e-mail]
Company Name E-mail Address
4641 Paragon Park Road 4641 Paragon Park Road
Current Mailing Address Current Street Address
Raleigh NC 27616 Raleigh NC 27616
City State Zip City State Zip
Phone: Office# 919.427.1646 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:
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 assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, Genera
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.
Robert L. Luddy President
Type or print name Title or Authority
2024.04.30
X Signature Date c-/p - 2p2y'
I, -01-PKa M , a Notary Public of the County of
State of North Carolina, hereby certify that C 1k.;r appeared personal)
before me this day and being duly sworn acknowledged that the abo0 form was executed 0 h miher
Witness my hand and notarial seal, this day of /�' ,
4/&
�
r Notary
N O Tlfi klY r7 0 '
PUBLIC — My commission expires

1
Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multipl
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 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 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.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#