NCC230613_FRO Submitted_20230308

Check if this project is ARPA-funded
FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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
NEW VISITOR CENTER
V this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land -disturbing activity: County Forsyth City or Township Kernersville
S. Main St. & Salisbury St. 36.1152-80.0788
Highway/Street LatltUde(dea{mal degrees) LonglkUde(decimel degrees)
3. Approximate date land -disturbing activity will commence: March 2023
Instilulioual8 puhlic�gndlpunal Use DiMoul
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.66
6. Amount of fee enclosed: $130.00 (previous fee -Paid) 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 Suzanna Ritz Malliett E-mail Address [e-mail]
Phone: Office # [phone] Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
The Korner's Folly Foundation [phone]
Name
413 South Main Street
Current Mailing Address
Kernersville, NC 27284
City
Phone: Office # Mobile it
413 South Main Street
Current Street Address
Kernersville, NC 27284
State Zip City
State
Zip
BUM, Pg2410;SUM. Pg2076 Bk3327, Pg 0131
10. Deed Book Na. Page No. 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 pany(ies)_
The Korner's Folly Foundation
Company Name
413 South Main Street
Current Mailing Address
Kernersville, NC 27284
[e-mail]
E-mail Address
413 South Main Street
Current Street Address
Kernersville, NC 27284
City State Zip City State Zip
Phone: Office # [phone] 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:
John G. Wolfe, III (deceased, 11/2022) (Secretary of State site, No updated information)
Name of Registered Agent
101 S. Main Street
Current Mailing Address
Kernersville, NC 27284
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of individual to Contact (if Registered Agent is a company)
State Zip
(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 Dame.
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.
Suzanna Ritz Malliett
Executive Director
Type or print name Title or Authority
2,1. w-T3
ig ure Dat
I,--,9ASern!,fS , a Notary Public of the County of F
State of North Carolina, hereby certify that _ S1JLA.NNPC Cck 2- e1T 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
Emy
JASON T. GBUBBS
ary Public, North Carolina
Fo.Fsy:th County
Commission Expires
August 21. 2025
day of , 20 ZS
Not ry
y commission expires Au6 cT 2.01 Z2 �

NEW VISITOR CENTER
(The Korner's Folly Foundation and Town of Kernersville)
South Main Street and Salisbury Street
Kernersville, NC
ADI Project #21-017
ADDITIONAL LANDOWNER OF RECORD:
PIN #6886-12-6750
Town of Kernersville
P.O. Box 728
Kernersville, NC 27284
[phone]
[e-mail]