NCC231497_FRO Submitted_20230524

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
an i an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.G. Department of Environmental Quality. Submit the completed form to the appropriate
Resiornal Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
nu ber is unavailable, place N/A in the blank.) NT#23038(BRUNS-2023-077)
Pa A.
1. Project Name Champion River Run Tract
2. Location of land-disturbing activity: County Brunswick City or Township Varnamt©wn
Highway/Street River Run Drive Latitude(dectmal degrees)33.949 Longltude(de,mal degrees)-78.227
3. Approximate date land-disturbing activity will commence: April 1 , 2023
4. Purpose of development(residential, commercial, industrial, institutional,etc.): Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 1 .48
6. Amount of fee enclosed: $200.00 . 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.
7. Has an erosion and sediment control plan been filed? Yes C] Enclosed II No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name J. Phillip Norris, P.E. E-mail Address [e-mail]
Phone: Office# 910-287-5900 Mobile# [phone]
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Roger Pierce 910-624-9222
Name Phone: Office# Mobile#
92 Pierce Drive 92 Pierce Drive
current Mailing Address Current Street Address
Lumber Bridge NC 28357 Lumber Bridge NC 28357
City State Zip City State Zip
10. Deed Book No.4862 Page No. 1318 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 owners)may be listed as the financially responsible party(ies).
Roger Pierce [e-mail]
Company Name E-mail Address
92 Pierce Dr 92 Pierce Dr
Current Mailing Address Current Street Address
Lumber Bridge, NC 28357 Lumber Bridge, NC 28357
City State Zip City State Z p
Phone: Office# 910-740-4102 Mobile# [phone]'!02
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
cont-ol 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:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
P
Phone: Office# 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 registy:
N/A
Ns me of Registered Agent E-mail Address
CL.rrent Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Na Tie of Individual to Contact(if Registered Agent is a company)

(c).f 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 aoove 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.
Roger Pierce Landowner
Type or print name Title or Authority
OP
Sign.ture Date
I, ekvttarkno-. 06201/4., Auktoir , a Notary Public of the County of gel:CAM
State of'North Carolina,hereby certify that C\Ootim appeared personally
before me this day and being duty sworn acknowledged that the above form was executed by him/her.
WitnesS my hand and notarial seal, this sAi day of -nibieell , 20 25
CANI;A.b.aro•-,1 ejkoivx-> isle-KAU('
Notary
Seal
My commission expires 2 ae
1

(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.
Roderick Wilkins Landowner
Type or print name Title or Authority
Signature Date
•
i, ,$mkitGn©' .L �,�t r , a Notary Public of the County of Alkifirn
State of North Carolina,hereby certify that ` d i 1, 1441Ad appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witless my hand and notarial seal,this 41 day of i-Mar , 20 3
•
p
gn
Notary
Seal
My commission expires 4416,34. �� go:t0

Con 'Hued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
own:•rs. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Roderick L. Wilkins 910-316-2112
Name Phone: Office# Mobile#
5286 Old Lowery Rd. 5286 Old Lowery Rd.
Current Mailing Address Current Street Address
Shannon NC 28386 Shannon NC 28386
City State Zip City State Zip
Deed Book No.4438 Page No.938 Provide a copy of the most current deed.
Lan.owner 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,
Lan'owner 4 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.
La downer 5 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.
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