NCC242919_FRO Submitted_20241009

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 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 Middle Fork Greenway Section 5 - Boone Gorge Park
2. Location of land-disturbing activity: County Watauga City or Township Boone
Highway/Street Old Blowing Rock Rd Latltude(decimal degrees)36.190126° -81.65734°
Long ltude(decimai degrees)
3. Approximate date land-disturbing activity will commence: Fall 2024/VVinter 2025
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Recreation
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 11 .9 acres
6. Amount of fee enclosed: $ 1+200.00 . 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. lias an erosion and sediment control plan been filed? Yes❑ Enclosed E5 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Wendy Patoprsty E-mail Address [e-mail]
Phone: Office# 828-264-2511 Mobile#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Blue Ridge Conservancy [phone]
Name Phone: Office# Mobile#
416 Aho Rd 416 Aho Rd
Current Mailing Address Current Street Address
Blowing Rock NC 28605 Blowing Rock NC 28605
City State Zip City State Zip
10. Deed Book No.2272 Page No.781 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 names)of the owner(s)may be listed as the financially responsible party(ies).
Watauga County [e-mail]
Company Name E-mail Address
814 W King Street 814 W King Street
Current Mailing Address Current Street Address
Boone NC 28607 Boone NC 28607
City State Zip City State Zip
Phone: Office# [phone] 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. (al tf 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, 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.
.UetU rJ c (eA C Iti‘t-AAt/ I��N[z nri� m:re G'f6/
Type or print name Title or Authority
2 9 - 2 o 2 ti
Signature Date
I, ARM, d rQ LP_ , a Notary Public of the County of W(Xfa 11
g
State of North Carolina, hereby certify that Delon n Co co u uQ appeared personally
before me this day and being duly sworn acknowledged that the aboform was executed by him/her.
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Witness my hand and notarial seal, this o�.. l day of 'tv`(-Axi , 20 24
Pr.ta ..F V
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r T. °9 = Notary
}F} --,� My commission expires (A,. 2. 2O2Lo
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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.
i.arnnrrvsner 2 of Record..
Watauga County [phone]
Name Phone: Office# Mobile#
814 W King Street 814 W King Street •
Current Mailing Address Current Street Address
Boone, NC 28607 Boone, NC 28607
City State Zip City Stake Zip
Deed Book No. 1 636 Page No.447 Provide a copy of the most current deed.
Landowner 3 of Record:
Appalachian State University [phone]
Name Phone: Office# Mobile#
438 Academy Street 438 Academy Street
Current Mailing Address Current Street Address
Boone, NC 28607 Boone, NC 28607
City State Zip City State Zip
Deed Book No.030 Page No.349 Provide a copy of the most current deed.
Landowner 4 of Record:
Appalachian State University [phone]
Name Phone: Office# Mobile#
438 Academy Street 438 Academy Street
Current Mailing Address Current Street Address
Boone, NC 28607 Boone, NC 28607
City State Zip City State Zip
Deed Book No.802 Page No.487 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#