NCC230766_FRO Submitted_20230328

Check if this project is ARPA-funded ❑
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, 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 N/A in the blank.)
Part A.
1. Project NamePelham Solar
*If 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: CountyCaswell City or Township Pelham
Highway/Street354 Gwynns Chapel Rd Latitude(aeGmel degrees) Longitude(aeGmel degrees)
3. Approximate date land -disturbing activity will commence: 02/ 2 2/ 23
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Solar Energy
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 341
6. Amount of fee enclosed: $___ . 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 p No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Grayson Newell _ E-mail Address gnewell blueridgeoower.com
Phone: Office # 8334361249 Mobile # $28 8202917
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Kenneth N & Donna P Echols
Name Phone: Office # Mobile #
859 Gwynn Chapel Rd
Current Mailing Address Current Street Address
Pelham, NC 27311
City State Zip City State Zip
10. Deed Book No. 57 7 Page No. 741 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).
Pine Gate Renewables
Company Name
130 Roberts St.
Current Mailing Address
Asheville, NC 28801
City State Zip
Phone: Office # 833 436 1249
[e-mail]
E-mail Address
Current Street Address
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:
Registered Agent Solutions Inc.
Name of Registered Agent
176 Mine Lake Court, Ste.100
Current Mailing Address
Raleigh, NC 27615
City
State
[e-mail]
E-mail Address
Current Street Address
zip City
Phone: Office # 800-906-9220 X123 Mobile # [phone]
Naomi Ostopowitz
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
City State
Phone: Office #
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State 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 #

(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.
Grayson Newell
print
S
Vice President
Title or Authority
2 /2 71Z 3
Date
I, M-61an(a UAY1r1 6 - al@Notary Public of the County of 'Bunr.(jJU1 i&
State of North Carolina, hereby certify that C-OObn 1 WA 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 , 20 2.3
........., `' a% Notary
My commission expireZ®*
s,� .fin` ,,, Gp��•
�'•a,BUNCOM��,•��

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:
Quercus Inc.
Name Phone: Office # Mobile #
PO Box 653
Current Mailing Address Current Street Address
Lewisville, NC 27023
City State Zip City State Zip
Deed Book No. 387 Page No. 612 Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
...,.d.......... A ..i o,.,.,..,d•
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office # Mobile #
Current Mailing Address
City
Deed Book No.
Current Street Address
State Zip City State Zip
Page No. _ Provide a copy of the most current deed.