NCC242564_FRO Submitted_20240826

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: North Carolina Highway 65
*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#
Yes Highway 65 Water Line Extension SRP-D-ARP-0047
2. Location of land-disturbing activity: County: Forsyth City or Township: Rural Hall
Highway/Street: 275 Rural Hall-Germanton Rd Latitude: 36.242394 Longitude: -
80.290845
3. Approximate date land-disturbing activity will commence: 10/14/2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Other: Utility - Potable
Water
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 6.60
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: Derek Stroud E-mail Address: [e-mail]
Phone: [phone] Mobile: [phone]
9. Landowner(s)of Record:
Landowner(s) of Record
Name Email Business Phone Mobile Phone
Winston-Salem/ Forsyth County Utilities [e-mail] 336-747-6840 336-442-6578
(WSFCU)
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
100 East First Winston- North 27101 P.O. Box 2511 Winston- North 27102
Street Salem Carolina Salem Carolina

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
Winston-Salem/ Forsyth County Utilities [e-mail] 336-747-6840 336-442-6578
(WSFCU)
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
100 East First Winston- North 27101 P.O. Box 2511 Winston- North 27102
Street Salem Carolina Salem Carolina
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
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
(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
Hazen and Sawyer [e-mail] 336-292-7490 910-975-4976
Physical Address Mailing Address
Street 1 City State Zip Street 1 City _ State Zip
620 Green Greensboro North 27408 620 Green Greensboro North 27408
Valley Road, Carolina Valley Road, Carolina
Suite 101 Suite 101

Additional Details
1. Stream Classification: C: Aquatic Life, Secondary Contact Recreation, Fresh water
2. Was Express Review Requested: No
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.

8/20/24,7:58 PM E&SC-Application Details
Division of Energy, Mineral, and Land Resources
Financial Responsibility/Ownership Form
Application Details Application Permissions
O O O O
Pending Application Submitted Technical Review Decision
14/01ing
•ication Submitted
ical Review
Decision
Permit Application Number Invoices
PA-004450
Invoice Nun Invoice Date i Due Date • Invoice Tota Total Paid
Total Acreage Disturbed or _
Uncovered 19 INV-002263 4/23/2024 4:48 AM 5/23/2024 4:48 AM $700.00 $700.00
6.6
Status
Issued
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Is This a New Plan Submission? Original Application Approved? Previous Project Not Found Previous Project/Permit Number
Yes
Permit Previous Application
FORSY-2024-0118
Purpose of Development Other (Describe)
Other Utility- Potable Water
ARPA Funded ARPA Project Name
Yes Highway 65 Water Line Extension
Approximate Date Land-Disturbing Activity Will Begin Engineering/Consulting Firm
10/14/2024 Hazen and Sawyer
Individual to contact for erosion &sediment control issues
Derek Stroud
Project Information
Environmental Interest Name Environmental Interest Type
North Carolina Highway 65
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8/20/24,7:58 PM E&SC-Application Details
Physical Address Mailing Address
275 Rural Hall-Germanton Rd
Rural Hall, NC 27045
County River Basin
Forsyth Roanoke
Stream Classification Trout Stream Encroachment
C:Aquatic Life, Secondary Contact Recreation, Fresh water No
Buffer Zone Acres Disturbed Length of Stream on Tract Buffer Width Reduction (ft)
Vegitation Trimming (ft) Channel Piping (ft) Channel Relocation (ft)
Total Buffer Impact (ft)
Primary Financially Responsible Party
Winston-Salem/Forsyth County Utilities (WSFCU)
Additional Financially Responsible Parties Landowners
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8/20/24,7:58 PM E&SC-Application Details
•Name Physical Street 1 Email Address Name Physical Street 1 Email Address
III
Winston-Salem/Forsyth
100 East First Street [e-mail]
County Utilities(WSFCU)
No Data Available
0 1 100 v items per page 0 1 100 v items per page 0
Registered Agent North Carolina Agent
Will Hard Copies of Calculations be Delivered? Will Hard Copies of E&SC Plans be Delivered? Calculations Not Applicable
No No Calculations Apply To My Project
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8/20/24,7:58 PM E&SC-Application Details
Documents
Document Name Document Size Created On Modified On
user_03 - Plan-Checklist-for-Designers-
206.89 KB 4/19/2024 3:09:44 PM 4/19/2024 3:09:44 PM
COM PLETE.pdf
FRO Application Report 05 06 2024 45.96 KB 5/6/2024 11:50:52 AM 5/6/2024 11:50:55 AM
11_50_52.docx
user_plans_07 32550-004 HWY 65 WL 90 79 614.73 KB 4/19/2024 3:03:46 PM 4/19/2024 3:04:16 PM
PCT DRAWINGS_SEALED_F.pdf
user_deed_06 -G22110_Final Signed
15,998.27 KB 4/19/2024 3:04:51 PM 4/19/2024 3:04:56 PM
Esmts_PDF.zip
user_04-401 WQC Approval_Hwy 65
818.20 KB 4/19/2024 3:09:45 PM 4/19/2024 3:09:45 PM
Waterline Extension_signed.pdf
user_05 - SAW-2023-02287 NWP 58
435.41 KB 4/19/2024 3:09:45 PM 4/19/2024 3:09:45 PM
verification.pdf
user_calculations_02- Highway 65 Water
11,642.29 KB 4/19/2024 3:09:00 PM 4/19/2024 3:09:06 PM
Line - Erosion Control Report.pdf
1 25 ' items per page 1 - 11 of 11 items 0
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