NCC242971_FRO Submitted_20240926

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
FINANCIAL RESPO NSIBILITY/O W IERSHIP FO IalI
SEDIM BVTATIO NPO LLUTIO NCO NITRO LACT
No person m air initiate any land-disturbing activity on one or m cre acres as covered by the Act, including any
activity under a corn m an plan of developm cit of this size as covered by the NCG 01 perm t, before this form
and an acceptable erosion and sedim citation control plan have been corn pleted and approved by the Land
Q Lality Section, N.C. Departm apt of Environm e-ital Q Lality. Subm t the corn Dieted form to the appropriate
Regional 0 fice. (Please type or print and, if the question is not applicable or the a-m al address or phone
num Ler is unavailable, place N/A in the blank.)
Part A.
1. Project Nam e Smith Rd
*If this project involves Am aican Rescue Plan Act(ARPA) funds, list the Project Nam e or Project
Num brr(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. L ocation of land-disturbing activity: County Davidson City or Township Lexington
Highway/Street Smith Rd Latitude(decimddegrees)35.789645 Long itude(decim d degrees)-80.208765
3. A pproxim ete date land-disturbing activity will corn m ance: 10/1/2024
4. P urpose of developm art(residential, corn m ecial, industrial, institutional, etc.): Residential
5. T otal acreage disturbed or uncovered (including off-site borrow and waste areas): 1.65
6. A mount of fee enclosed: $ 200 . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling am cunt (Exam pie: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ .
7. H as an erosion and sedim ent control plan been filed? Yes Enclosed ❑ No ❑
8. P erson to contact should erosion and sedim ant control issues arise during land-disturbing activity:
Name Daniel Everhart E_m al Address [e-mail]
Phone: 0 fice# 336-596-1753 M cbile# 336-596-1753
9. L andowner(s)of Record (attach accom panied page to list additional owners):
PoP Homes - GSO LLC 336-596-1753 336-596-1753
Name Phone: 0 fice#o M bile#
464 Rickard Drive _ 464 Rickard Drive
Current M aling Address C urrent Street Address
Winston Salem NC 27101 Winston Salem NC 27101
City S tate Z ip C ity S tate Zip
10. D eed Book No. 2665 Page No. 791-793 Provide a copy of the m cst current deed.

Part B.
1. Corn pany(ies)who are financially responsible for the land-disturbing activity(Provide a corn prehensive list
of all responsible parties on accom partied page.) If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the nam e(s) of the owner(s)m ay be listed as the financially responsible party(ies).
PoP Homes - GSO LLC [e-mail]
Company Name E -m al Address
464 Rickard Drive 464 Rickard Drive
Current M cling Address C urrent Street Address
Winston Salem NC 27101 Winston Salem NC 27101
City S tate Z ip C ity S tate Zip
Phone: 0 fice# 336-596-1753 M chile# 336-596-1753
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 subm t 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 nam eand street address of the Registered Agent:
Emily J. Meister [e-mail]
Name of Registered Agent E -m al Address
6323 North Elm Street Suite 200 6323 North Elm Street Suite 200
Current M cling Address C urrent Street Address
Greensboro NC 27455 Greensboro NC 27455
City S tate Z ip C ity S tate Zip
Phone: 0 fice# 336-378-1899 M cbile#
Name of Individual to Contact(if Registered Agent is a com pany)
(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 -m al Address
Current M cling Address C urrent Street Address
City S tate Z ip C ity S tate Zip
Phone: 0 fice# M chile#
Nam eof Individual to Contact(if Registered Agent is a corn pany)

(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.
Daniel Everhart Manager
Type or print name Title or Authority
Dom,, ,e CU,e,t 9/20/2024
Signature Date
I, Loy-t 'O Gv±eS _, a Notary Public of the County of at,t I f r't-
State of North Carolina,hereby certify that Dame 1 (�ye{1 t Qr-f- appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
• .fir^
Witness my hand and notarial seal, this�O day of S(9p t- bey-, 20 a 4
d)z .( Oc -
Notary
My commission expires 10 cC 'aS
Lori Oates
NOTARY uJQUC
G.dfora f' ',i)t, NC
My Commission Expires October 20,2025

Continued from Items 9 & 10 in Part A of the Financial Responsibility/0 wiership Form for m LItiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name P hone: O fice#o M bile#
Current M sling Address C urrent Street Address
C ity S tate Z ip C ity S tate Zip
D eed Book No. Page No. Provide a copy of the m ost current deed.
Landowner 3 of Record:
Name P hone: O fice#o M bile#
Current M sling Address C urrent Street Address
C ity S tate Z ip C ity S tate Zip
D eed Book No. Page No. Provide a copy of the m cst current deed.
Landowner 4 of Record:
Name P hone: O fice#o M bile#
Current M sling Address C urrent Street Address
C ity S tate Z ip C ity S tate Zip
D eed Book No. Page No. Provide a copy of the m cst current deed.
Landowner 5 of Record:
Name P hone: O fice#o M bile#
Current M ailing Address C urrent Street Address
C ity S tate Z ip C ity S tate Z ip
D eed Book No. Page No. Provide a copy of the m cst current deed.

Continued from Item 1 in Part B of the Financial Responsibility/0 w►ership Form for m atiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Nam e E -m al Address
Current M cling Address C urrent Street Address
City S tate Z ip C ity S tate Zip
Phone: 0 fice# M chile#
Company 3 Nam e E -m al Address
Current M cling Address C urrent Street Address
City S tate Z ip C ity S tate Zip
Phone: 0 fice# M cbile#
Company 4 Nam e E -m al Address
Current M cling Address C urrent Street Address
City S tate Z ip C ity S tate Zip
Phone: 0 fice# M chile#
Corn pany 5 Nam e E -m al Address
Current M cling Address C urrent Street Address
City S tate Z ip C ity S tate Zip
Phone: 0 fice# M cbile#