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Home My WebLink AboutNCC242682_FRO Submitted_20240830 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: Golden Hills Mitigation Site *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: Guilford City or Township: Greensboro Highway/Street: 5980 Davis Mill Rd Latitude: 35.940187 Longitude:-79.797013 3. Approximate date land-disturbing activity will commence: 10/1/2024 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Other: Stream restoration 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 52.48 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: Noyes Harrigan E-mail Address: nharrigan@wildlandseng.com Phone: 9802297898 Mobile: 9802297898 9. Landowner(s)of Record: Landowner(s) of Record Name Email Business Phone Mobile Phone William Burgess Rhodes Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 5922 Davis Mill Rd Greensboro NC 27406 5922 Davis Mill Rd Greensboro NC 27406 Name Email Business Phone Mobile Phone Lawrence C Ross Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 5980 Davis Mill Rd Greensboro NC 27406 6002 Davis Mill Rd Greensboro NC 27406 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 Wildlands Engineering swilkerson@wildlandseng.com 7043327754 7044581836 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 1430 S. Mint St, Charlotte North 28203 1430 S. Mint St, Charlotte North 28203 Suite 104 Carolina Suite 104 Carolina Additional Financially Responsible Parties _ Company Name Email Business Phone Mobile Phone Wildlands Engineering swilkerson@wildlandseng.com 7043327754 7044581836 Physical Address Mailing Address _ Street 1 City State Zip Street 1 _ City State Zip 1430 S. Mint St, Charlotte North 28203 1430 S. Mint St, Charlotte North 28203 Suite 104 Carolina Suite 104 Carolina 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 Wildlands Engineering swilkerson@wildlandseng.com 7043327754 7044581836 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 1430 S. Mint St, Charlotte North 28203 1430 S. Mint St, Charlotte North 28203 Suite 104 Carolina Suite 104 Carolina (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 Wildlands Engineering nharrigan@wildlandseng.com 7043327754 9802297898 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 1430 S. Mint St, Charlotte NC 28203 1430 S. Mint St, Charlotte NC 28203 Suite 104 Suite 104 Additional Details 1. Stream Classification: WS-III: Water Supply Ill 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.