NCC230185_FRO Submitted_20230123

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 NIA in the blank.)
Part A.
1. Project Name Williams Grove Lots 94, 95, 96 (Deed Book and Page number: 3143: 483-491)
2. Location of land -disturbing activity: County Nash City or Township Bailey
Highway/Street Stoney Hill Church Rd Latitude(decimaldegrees) 35.808055 Long itude(deamatdegrees) .-78.066965
3. Approximate date land -disturbing activity will commence: 2/13/23
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.54 acres
6. Amount of fee enclosed: $ payment previously sent . 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 ;Z No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jordan Riley E-mail Address [e-mail]
Phone: Office # 919-987-1930 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
C.T. WILLIAMS CORPORATION 252-205-1151
Name Phone: Office # Mobile #
3303 SUNSET AVE, STE H 3303 SUNSET AVE, STE H
Current Mailing Address Current Street Address
ROCKY MOUNT NC 27804 ROCKY MOUNT NC 27804
City State Zip City State Zip
10. Deed Book No. 3143 page Na 483-491 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).
NVR, INC.
Company Name
RALEIGH 5734 Trinity Rd, Suite 200
DIVISION
Current Mailing Address
Raleigh, NC 27607
City
State Zip
Phone: Office # 919-987-1930
[e-mail] [e-mail]
E-mail Address
CORPORATE
11700 PLAZA AMERICA DR #500 OFFICE
Current Street Address
RESTON VA 20190
City State Zip
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:
NIA
Name of Registered Agent
NIA
Current Mailing Address
NIA
Email Address
NIA
Current Street Address
NIA NIA
City State Zip City State Zip
Phone: Office # NIA Mobile # NIA
NIA
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:
MATT WINKLER (NVR, INC.) [e-mail]
Name of Registered Agent E-mail Address
RALEIGH CORPORATE
DIVISION 6734 TRINITY ROAD, STE 200 11700 PLAZA AMERICA DR #500 OFFICE
Current Mailing Address Current Street Address
RALEIGH NC 27607 RESTON VA 20190
City State Zip City State Zip
Phone: Office # 919-987-1930 Mobile # NIA
MATT WINKLER
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 Dame.
tJA
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.
MATT WINKLER �� DIVISION MANAGER
Type or
Title or Authority
2 it rL�
Date
I, i Y "02 66 a Notary Public of the County of �`�
State of North Carolina, hereby certify that W0141'e'r 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 30�}day of 'I) e,--MjF20 ;-2--
Notary
Seal L; I �Z My commission expires
4
MINNIE WOODLEY
NOTARY PUBLIC
Wake County
North Carolina
My Commission Expires Sept. 25, 2024