NCC242102_FRO Submitted_20240715

Check if this project is ARPA-funded
p l ❑
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 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 American Beech Solar, LLC
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Halifax City or Township Scotland Neck
Highway/Street Sand Pit Rd Latitude(decimal degrees)36.143 Longltude(decimal degrees) -77 497
3. Approximate date land-disturbing activity will commence: 8/1/24
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Solar
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 966.3
6. Amount of fee enclosed: $96700 . 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 El No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Mathew Perry E-mail Address [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Larry T Pendleton
Name Phone: Office# Mobile#
106 Main St
Current Mailing Address Current Street Address
Scotland Neck, NC, 27874
City State Zip City State Zip
Page No.262
10. Deed Book No.2462 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).
Pure Power Contractors, LLC [e-mail]
Company Name E-mail Address
2812 Gray Fox Rd 2812 Gray Fox Rd
Current Mailing Address Current Street Address
Monroe, NC, 28110 Monroe, NC, 28110
City State Zip City State Zip
Phone: Office# 877-749-2852 Mobile#
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:
Justin Taylor [e-mail]
Name of Registered Agent E-mail Address
2812 Gray Fox Rd. 2812 Gray Fox Rd.
Current Mailing Address Current Street Address
Monroe NC 28110 Monroe NC 28110
City State Zip City State Zip
Phone: Office# 877-749-2852 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, 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.
Kirk Kieffer Member
Type or ' m Title or Authority
4/2/24
Signature Date
I, L.c 2 L. �Q�C c , a Notary Public of the County of w(t k P ,
State of North Carolina, hereby certify that lei(V- 1C1 �� r appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/Jf:
Witness my hand and notarial seal, this irrl day of r-` , 20 '4
Gip m.,�6 cc)(p-,
Notary
ea 1
„y My commission expires ¶ ' I ( ' 2O2,3
tip G

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Robert Benson Partin,Thomas Lawrence Partin
Name Phone: Office# Mobile#
1808 Church St
Current Mailing Address Current Street Address
Scotland Neck, NC, 27874
City State Zip City State Zip
Deed Book No. 1671 Page No. 151 Provide a copy of the most current deed.
Landowner 3 of Record:
George H Johnson Jr,Ann J Shields,Sarah J Bunting,Elizabeth J Phillips
Name Phone: Office# Mobile#
1734 Church St
Current Mailing Address Current Street Address
Scotland Neck, NC, 27874
City State Zip City State Zip
Deed Book No. 14-E Page No.519 Provide a copy of the most current deed.
Landowner 4 of Record:
Greenwood Farms LLC
Name Phone: Office# Mobile#
PO Box 424
Current Mailing Address Current Street Address
Scotland Neck, NC, 27874
City State Zip City State Zip
Deed Book No.2397 Page No.536 Provide a copy of the most current deed.
Landowner 5 of Record:
Jo Thompson Peele
Name Phone: Office# Mobile#
1207 Ray Turner Rd
Current Mailing Address Current Street Address
Oak City, NC, 27857
City State Zip City State Zip
Page No.230 Deed Book No. 1315 Provide a copy of the most current deed.

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Laurie Thompson Hubbard
Name Phone: Office# Mobile#
6304 Morganton Rd
Current Mailing Address Current Street Address
Fayetteville, NC, 28314
City State Zip City State Zip
Deed Book No. 1315 Page No.220 Provide a copy of the most current deed.
Landowner 3 of Record:
Trudy Crowder Tudor
Name Phone: Office# Mobile#
3575 Bynums Bridge Rd
Current Mailing Address Current Street Address
Scotland Neck, NC, 27874
City State Zip City State Zip
Deed Book No. P2011 Page No.96 Provide a copy of the most current deed.
Landowner 4 of Record:
Tony Lee Hale,Trustee of the Tony Lee Hale Revocable Trust
Name Phone: Office# Mobile#
5905 SandPit Rd
Current Mailing Address Current Street Address
Scotland Neck, NC, 27874
City State Zip City State Zip
Deed Book No.2469 Page No.465 Provide a copy of the most current deed.
Landowner 5 of Record:
L&K Enterprises of Sandy Cross, LLC
Name Phone: Office# Mobile#
• 2932 Sandy Cross Rd
Current Mailing Address Current Street Address
Nashville, NC, 27856
City State Zip City State Zip
Page No.514
Deed Book No.2323 Provide a copy of the most current deed.

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Robert Benson Partin,Thomas Lawrence Partin
Name Phone: Office# Mobile#
1808 Church St
Current Mailing Address Current Street Address
Scotland Neck, NC, 27874
City State Zip City State Zip
Deed Book No. 1688 Page No.64 Provide a copy of the most current deed.
Landowner 3 of Record:
Trudy Crowder Tudor
Name Phone: Office# Mobile#
3575 Bynums Bridge Rd
Current Mailing Address Current Street Address
Scotland Neck, NC, 27874
City State Zip City State Zip
Deed Book No.2332 Page No.303 Provide a copy of the most current deed.
Landowner 4 of Record:
Trudy Crowder Tudor
Name Phone: Office# Mobile#
3575 Bynums Bridge Rd
Current Mailing Address Current Street Address
Scotland Neck, NC, 27874
City State Zip City State Zip
Deed Book No. 1435 Page No.61 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.