NCC232162_FRO Submitted_20230721

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 N/A in the blank.)
Part A.
1. Project NameFox Field Farms
2. Location of land-disturbing activity: County Harnett City or Township Upper Little River
Highway/Street SR 1291 Latitude(decnat degrees)35.4324 Longitude(dedmaldegrees)-79.0037
3. Approximate date land-disturbing activity will commence:07-01-2023
4. Purpose of development(residential,commercial, industrial, institutional, etc.):residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 12.3
6. Amount of fee enclosed: $1300.00 . 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❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Seth Thompson E-mail Address [e-mail]
Phone: Office# [phone] Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
KATHERYN THOMAS MEDLEY&JEFFREY B.THOMAS
Name Phone: Office# Mobile#
102 WINTERLOCHEN DR 102 WINTERLOCHEN DR
Current Mailing Address Current Street Address
DUNN, NC 28334 DUNN, NC 28334
City State Zip City State Zip
10. Deed Book No, 3565 Page No.743 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).
RP WELLONS LAND&DEVELOPMENT, LLC [e-mail]
Company Name E-mail Address
2004 W. CUMBERLAND STREET 2004 W. CUMBERLAND STREET
Current Mailing Address Current Street Address
Dunn NC 28334 Dunn NC 28334
City State Zip City State Zip
Phone: Office# [phone] Mobile# [phone]
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:
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)
(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)

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:
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 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.
Landowner 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.
Landowner 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.

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
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.
Robert P. Wellons Manager
T7Drint name k Title or Authority
Signature Date
I, - Clmrrly N. -1-6C cc-cn , a Notary Public of the County of 4-IQv(1C'
State of North Carolina, hereby certify that p4 r(k ?. Hle\tone, 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 NIQL.4 , 20 (3
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NCDEQ-EMLR
225 GREEN STREET,SUITE 714
FAYETTEVILLE,N. C. 28301
Re: Fox Field Farms-Owners Consent
To Whom It May Concern:
Katheryn T.Medley and Jeffrey B.Thomas hereby authorize RP Wellons Land &
Development, LLC to submit an erosion control plan on their behalf and grant
permission for land disturbance and submission for NCDEQ erosion control permit for
Fox Feild Farms Subdivision-NC PIN 9691-91-1036.000
5--3o -,(9,o)-3
Katheryn T. edley Date
Y
a 3
ey$!Thomas Da

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' DATE INVOICE NO. DESCRIPTION INVOICE AMOUNT DEDUCTION BALANCE
5-30-23 FoxField Fox Field Farms NCI) 1300 . 00 1300 . 00
CHECK► CHECK ► TOTALS ►
DATE 5-30-23 NUMBER 1665 1300 . 00 1 3Q0 - 00
PLEASE DETACH THIS PORTION AND RETAIN FOR YOUR RECORDS
�pOC�I�{ENj'1S:PR{NTEDgO Ck1E�C-Ai�YtR�1T1YE P/tiPER 1HE'.BACiCOF THIS DOGUM�NT INCCI?OES ATp67PER EVIDENT C}iEf,,,CgL SNASFi G/ARNING.BOX .s8 ,_ -�`. ¢,;
RP WELLONS LAND & DEVELOPMENT LLC FIDELITY BANK 1665
P.Q. BOX 730 "RIGHT BY YOU"
DUNN,NC 28335 1000 EAST CUMBERLAND ST.
DUNN,NC 28334
66-358/531
Pay: *************************One thousDAn..ird three hundre Ed ars andA oUN?ents
May 30, 2023 1665 $******1, 300 . 00
PAY
TO THE
NCDEQ RP WELLONS LAND&DEVELOPMENT LLC
S SEXJ/�
ORDER 217 West Jones Street °P
OF Raleigh, NC 27603 0
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RP WELLONS LAND & DEVELOPMENT LLC 1665
32474866.PDF 3-18-2021-LP MOD9321