NCC230145_FRO Submitted_20230118

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 NameHAWTHORNE AT SOUTHBRIDGE
2. Location of land -disturbing activity: County ONSLOW City or Township SNEADS FERRY
Highway/Street H W 172 Latltude(decimai degrees) 34.558583 Longitude(decimai degrees) -77.406846
3. Approximate date land -disturbing activity will commence: 3/30/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Multifamily Resid.
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 18.23 acres
6. Amount of fee enclosed $1 X0 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). 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:
NameMICHAEL BUCKLAND E-mail Address [e-mail]
Phone: Office # 910-239-9120 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
HAWTHORNE SNEADS FERRY ADDITION LLC 910-239-9120
Name Phone: Office # Mobile #
2918-A Martinsville Road 2918-A Martinsville Road
Current Mailing Address Current Street Address
Greensboro, NC 27408 Greensboro, NC 27408
City State Zip City State Zip
10. Deed Book No. 5749 Page No. 804 Provide a copy of the most current deed.
(SEE PAGE 4 FOR ADDITIONAL LANDOWNERS OF RECORD)

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 orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
HAWTHORNE SNEADS FERRY ADDITION LLC
Company Name
2918-A Martinsville Road
Current Mailing Address
Greensboro, NC 27408
[e-mail]
E-mail Address
2918-A Martinsville Road
Current Street Address
Greensboro, NC 27408
City State Zip City State Zip
Phone: Office # 910-239-9120 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. (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:
Stephen C. Pritchard [e-mail]
Name of Registered Agent
804 Green Valley Rd Ste 200
Current Mailing Address
Greenboro NC, 27408
City State Zip
Phone: Office # 336.275.7626
E-mail Address
804 Green Valley Rd Ste 200
Current Street Address
Greenboro NC, 27408
City State Zip
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
(SEE PAGE 5 FOR ADDITIONAL FINANCIALLY RESPONSIBLE PARTIES)

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
(d) If 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:
Engineering firm or other consultant E-mail Address
Individual contact person (type or print) Phone: Office # Mobile #
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 infor tion should there be any change in the information provided herein.
Michael i tead Manager
Type or p i n Title or Authority
Signat r Date
I, zi e A Ae Notary Public of the County of a #gweq M/
r, �>l
State of North Carolina, hereby certify that � G�i ee ,-o 5 id� appeared personally
before me this day and being duly sworn acknowlgdged that
the above form was executed by him/her.
Witness my hand and notarial seal, thisA2�p"day of
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4 a r + �f My commission expires
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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.
Landowner 2 of Record:
HIM STILLWATER LLC, COLUMBIA STILLWATER LLC, AND THOMAS & HOWARD STILLWATER LLC
910-239-9120
Name
Phone: Office # Mobile #
2918-A Martinsville Road
2918-A Martinsville Road
Current Mailing Address
Current Street Address
Greensboro, NC 27408
Greensboro, NC 27408
City State
Zip
City State Zip
5749
798
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
HAWTHORNE AT SNEADS FERRY APARTMENTS LLC 910-239-9120
Name
Phone: Office # Mobile #
2918-A Martinsville Road
2918-A Martinsville Road
Current Mailing Address
Current Street Address
Greensboro, NC 27408
Greensboro, NC 27408
City State
Zip
City State Zip
5749
786
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Current Mailing Address
City
Deed Book No.
Landowner 5 of Record
Phone: Office #
Current Street Address
State Zip City
Page No.
Name
Current Mailing Address
City State
Deed Book No.
Mobile #
State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
Zip City State Zip
Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
HIM STILLWATER LLC, COLUMBIA STILLWATER LLC, AND THOMAS& HOWARD STILLWATER LLC [e-mail]
Company 2 Name E-mail Address
2918-A Martinsville Road 2918-A Martinsville Road
Current Mailing Address Current Street Address
Greensboro, NC 27408 Greensboro, NC 27408
City State Zip City State Zip
Phone: Office # 910-239-9120 Mobile #
HAWTHORNE AT SNEADS FERRY APARTMENTS LLC [e-mail]
Company 3 Name
2918-A Martinsville Road
Current Mailing Address
Greensboro, NC 27408
City State
Phone: Office # 910-239-9120
E-mail Address
2918-A Martinsville Road
Current Street Address
Greensboro, NC 27408
Zip City State
Mobile #
Zip
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 #