NCC243378_FRO Submitted_20241104

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: Bootstrap Mitigation Site
2. Location of land-disturbing activity: County Gaston City or Township Bessemer City
Highway/Street: Concord Church Rd Latitude(dec/deg)35.343 N , Longitude(dec/deg)-81.3015 W
3. Approximate date land-disturbing activity will commence: November 1, 2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Environmental restoration
for mitigation
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas: 29.3 acres
6. Amount of fee enclosed: $3,000.00. 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. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Abigail Vieira E-mail Address [e-mail]
Phone: Office#571-257-4266 x 102 Mobile#[phone]
1. Landowner(s)of Record (attach accompanied page to list additional owners):
David and Lisa Stroup (Attorney-Walt Grayson) 704-864-6751 704-629-2751
Name Phone: Attorney# Home#
1402 Dameron Rd 1402 Dameron Rd
Current Mailing Address Current Street Address
Bessemer City NC 28016 Bessemer City NC _ 28016
City State Zip City State Zip
2. Deed Book No. 4956 Page No. 929-938 _ Provide a copy of the most current deed.
SEE ADDITIONAL PAGES AT END OF FORM
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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).
Wildlands Holdings IX, LLC [e-mail]
Company Name E-mail Address
1430 S. Mint Street, Suite 104 1430 S. Mint Street, Suite 104
Current Mailing Address Current Street Address
Charlotte NC 28203 Charlotte NC 28203
City State Zip City State Zip
Phone: Office#[phone] Mobile# [phone]
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
Wildlands Holdings IX, LLC swilkerson(a�wildlandseng.com
Company Name E-mail Address
1430 S. Mint Street, Suite 104 1430 S. Mint Street, Suite 104
Current Mailing Address Current Street Address
Charlotte NC 28203 Charlotte NC 28203
City State Zip City State Zip
Phone: Office#[phone] Mobile#[phone]
Shawn Wilkerson
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
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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.
Shawn D. Wilkerson President
Type or print name Title or Authority
8/22/2024
Signat a Date
I, //Ober. 4- tv. /3`'8'1 , a Notary Public of the County of /hccIc/e- 6✓,
State of North Carolina, hereby certify that 5A Li///1,--e,',ScP-v appeared personally before me this
day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 22 day of A4� , 20 02
\\\\\\\\ Sc W 4 Notary
Q 3 �026
Notary Publk My commission expires
Mecklenburg
County
,ry CAa0`',.�"`
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ADDITIONAL LANDOWNER INFORMATION
3. Landowner(s)of Record (attach accompanied page to list additional owners):
Martha Stroup Trust (Attorney Greg Huffman) 828-322-7741 828-381-8666
Name Phone: Attorney# Mobile#
560 6th Street NW 560 6th Street NW _
Current Mailing Address Current Street Address
Hickory NC 28601 Hickory NC _ 28601
City State Zip City State Zip
4. Deed Book No. 5077 Page No. 1023-1030 Provide a copy of the most current deed.
5. Landowner(s)of Record (attach accompanied page to list additional owners):
Delisa and Chris Harrison N/A 704-813-7711
Name Phone: Office# Mobile#
403 36th Ave 403 36th Ave
Current Mailing Address Current Street Address
N. Myrtle Beach SC 29582 N. Myrtle Beach SC 29582
City State Zip City State Zip
6. Deed Book No. 4956 Page No. 959-968 Provide a copy of the most current deed.
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Jessica Certain _ _ N/A 704-830-8340
Name Phone: Office# Mobile#
125 Sherrill Drive 125 Sherrill Drive
Current Mailing Address Current Street Address
Fuquay Varina NC 27526 Fuquay Varina NC 27526
City State Zip City State Zip
8. Deed Book No. 4956 Page No. 939-948 Provide a copy of the most current deed.
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Barbara Stroup Lawing N/A 704-616-0295
Name Phone: Office# Mobile#
247 Helton Rd 247 Helton Rd
Current Mailing Address Current Street Address
Cherryville NC 28021 Cherryville NC 28021
City State Zip City State Zip
10. Deed Book No. 4962 Page No. 816-821 Provide a copy of the most current deed.
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11. Landowner(s)of Record (attach accompanied page to list additional owners):
Benita Stroup Kelbaugh N/A 704-491-4411
Name Phone: Office# Mobile#
302 Mark St 302 Mark St
Current Mailing Address Current Street Address
Cherryville NC 28021 Cherryville NC 28021
City State Zip City State Zip
12. Deed Book No. 4962 Page No. 810-815 Provide a copy of the most current deed.
13. Landowner(s)of Record (attach accompanied page to list additional owners):
Wildlands Engineering, INC 704-332-7754 704-458-1836
Name Phone: Office# Mobile#
1403 S. Mint St, Suite 104 1403 S. Mint St, Suite 104
Current Mailing Address Current Street Address
Charlotte NC 28203 Charlotte NC 28203
City State Zip City State Zip
14. Deed Book No. 5451 Page No. 2141-2144 Provide a copy of the most current deed.
15. Landowner(s)of Record (attach accompanied page to list additional owners):
Paul and Rita Ankrom N/A 704-729-6008
Name Phone: Office# Mobile#
155 Concord Church Rd 155 Concord Church Rd
Current Mailing Address Current Street Address
Bessemer City NC 28016 Bessemer City NC 28016
City State Zip City State Zip
16. Deed Book No. 4419 Page No. 594-610 Provide a copy of the most current deed.
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