NCC221904_FRO Submitted_20220520

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 Laurel Valley Mitigation Site
2. Location of land -disturbing activity: County Burke City or Township Morganton
3. Highway/Street 3623 Hawkins Drive Latitude(deade9) 35.703225' N Longitude(deGde9)-81.642877- W
4. Approximate date land -disturbing activity will commence: April 1, 2022
5. Purpose of development (residential, commercial, industrial, institutional, etc.): Environmental restoration
for mitigation
6. Total acreage disturbed or uncovered (including off -site borrow and waste areas: 15 acres
Amount of fee enclosed: $1,500.00. 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.
8. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed M No ❑
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Eric Neuhaus E-mail Address eneuhaus(cD-wildlandseng.com
Phone: Office # [phone] X105 Mobile # [phone]
10. Landowner(s) of Record (attach accompanied page to list additional owners):
John Hewat, Jr. N/A [phone]
Name Phone: Office # Mobile #
3923 Hawkins Drive 3923 Hawkins Drive
Current Mailing Address Current Street Address
Morganton NC 28655 Morganton NC 28655
City State Zip City State Zip
11. Deed Book No. 740 Page No. 1512 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 name(s) of the owner(s) may be listed as the financially responsible party(ies).
Wildlands Engineering. Inc swilkerson&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]
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 Engineering, Inc swilkerson wildlandsen .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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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.
Shawn D. Wilkerson
Type or print name
WAOWt
President
Title or Authority
4/26/2022
Date
I, � a Notary Public of the County of /VI f4kj cn%�
State of North Carolina, hereby certify that GWr► tot) 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 _;?�day of , 20Z2— -
FC di"', AIR 41 [�T r
NOTARY PUBLIC
LVeaVenburg Countv.. North C`�
Notary
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