NCC216135_FRO Submitted_20211104

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 and/or
fax information unavailable, place N/A in the blank.)
Part A. 1. Project NameLoflin gold Mine Test Site Ph. 2
2. Location of land -disturbing activity: CountyRandolph City or TownshipTrinity
Highway/StreetLoflin Hill Rd Latitude35.723807 Longitude-80.044109
3. Approximate date land -disturbing activity will commence: Nov. 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.) Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas? 4
6. Amount of fee enclosed: $ (260)(1000) The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7 Has an erosion and sediment control plan been filed? Yes No EnclosedX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJonathan Powers E-mail Address [e-mail]
Telephone[phone] Cell # 919-673-3134 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Jerome Church n/a n/a
Name Telephone Fax Number
1265 Loflin Hill Rd 1265 Loflin Hill Rd
Current Mailing Address Current Street Address
Trinity NC 27370 Trinity NC 27370
City State Zip City State Zip
10. Deed Book No.21 33 Page No.889 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Project J KL, LLC [e-mail]
Name E-mail Address
204 Bernard Purvis Rd 204 Bernard Purvis Rd
Current Mailing Address Current Street Address
Bennett NC 27208 Bennett NC 27208
City State Zip City State Zip
Tolephone 919-650-1158 Fax Number n/a

9. Landowner(s) of Record (attach accompanied page to list additional owners)
Tammy Crigger
n/a n/a
Name
_
Telephone Fax Number
1211 Loflin Hill Rd
1211 Loflin Hill Rd
Current Mailing Address
Current Street Address
'I"rinity NC
27370
Trinity NC 27370
City State
Zip
City State Zip
10. Deed Book No. 1849
Page No.
69 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach
accompanied
page to list additional owners):
Todd Daniels
n/a n/a
Name
Telephone Fax Number
1145 Loflin Hill Rd
1145 Loflin Hill Rd
Current Mailing Address
Current Street Address
Trinity NC
27370
Trinity NC 27370
City State
Zip
City State Zip
10. Deed Book No. 1506
Page No.
179 Provide a copy of the most current deed.
A"
Landowner(s) of Record (attach accompanied page to list additional owners):
Amanda Kreiter n/a
Name Telephone
1234 Loflin Hill Rd 1234 Loflin Hill Rd
Fax Number
Current Mailing Address Current Street Address
Trinity NC 27370 Trinity NC 27370
City State Zip City State Zip
10. Deed Book No. 2765 Page No. 336 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Robert Moran n/a n/a
Name Telephone Fax Number
1500 Fawn Drive 1500 Fawn Drive
Current Mailing Address Current Street Address
Asheboro NC 27205 Asheboro NC 27205
City State Zip City State Zip
10. Deed Book No. 2019 Page No. 968 Provide a copy of the most current deed.

9. Landowner(s) of Record (attach accompanied page to list additional owners):
Craig Wagoner n/a
Name
1190 Loflin Hill Rd
Current Mailing Address
Trinity NC
City State
10. Deed Book No. 2742
n/a
Telephone Fax Number
1190 Loflin Hill Rd
Current Street Address
27370 Trinity NC 27370
Zip City State Zip
Page No._ 1200 Provide a copy of the most current deed.

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
n/a
n/a
Name
E-mail Address
n/a
n/a
Current Mailing Address
Current Street Address
n/a
n/a
City State Zip
City State Zip
Telephonen/a
Fax Numbern/a
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Jonathan Powers
[e-mail]
Name of Registered Agent
E-mail Address
204 Bernard Purvis Rd
204 Bernard Purvis Rd
Current Mailing Address
Current Street Address
Bennett NC 27208
Bennett NC 27208
City State Zip
City State Zip
Telephone[phone]
Fax Numbern/a
(c) In order to facilitate Express Permitting, it
is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Summey Engineering Associates, PLLC
[e-mail]
Engineering Firm or other consultant
E-mail Address
Christian Vestal
336-328-0902 n/a
Individual contact person (type or print)
Telephone Fax Number
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 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 Person). I agree to provide corrected information should there be
any change in the information provided herein.
Jonathan Powers
Type or print ame
ignature
Vice President
Title or Authority,,
' DC.�.' 2 D 2.1
Date
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CS a Notary Public of the County of `�olph
State of North Carolina, hereby certify that Jorxat�n 'Vn�_ue,(S appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this Zloday of oC_-tobe,(- , 202'
QL n I -An I JAJUA4_11)
Seal
My commission expires '$ . 2q - 2O115-