NCC240311_FRO Submitted_20240209

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 and/or fax information
unavailable, place N/A in the blank.)
Part A.
1. Project Name Hadley Acres - Phase 2
2. Location of land-disturbing activity: County Wayne City or Township Goldsboro
Higha: iy/Street Hadley Drive Latitude 35.3135 Longitude-77.8548
3. Approximate date land-disturbing activity will commence:June 2022
4. Purpose of development(residential, commercial, industrial, institutional, etc ): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):6.0
6. Amount of fee enclosed: $600.00 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).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Matt Spence E-mail Address [e-mail]
Telephone [phone] Cell# 252-917-1458 Fax# N/A
9. Landowner(s)of Record (attach accompanied page to list additional owners).
BS2 ENDEAVOURS LLC 919-242-4600 N/A
Name Telephone Fax Number
115 SUSAN CIR 115 SUSAN CIR
Current Mailing Address Current Street Address
GOLDSBORO NC 27530 GOLDSBORO NC 27530
City State Zip City State Zip
10. Deed Book No.2861 Page No. 847 Provide a copy of the most current deed
Part B.
1. Company (ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Construction Managers, Inc. [e-mail]
Name E-mail Address
PO Box 1138 104 S Sycamore St
Current Mailing Address Current Street Address
Fremont NC 27830 Fremont NC 27830
City State Zip City State Zip

Telephone [phone] _ Fax Number N/A
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of
the designated North Carolina Agent:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party
is a Corporation, give name and street address of the Registered Agent:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number-N/A
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
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Type or prin name Title or Authority
ign Date
I, Sk\ red 1\ , a Notary Public of the County of kigrt.
State of North Carolina, hereby certify that scvnn"y 1-- S9SSQr appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.Witness my hand and notarial seal, this a-,J day of u(Ne , 20 a')'
AUSTIN TERRELL—
NOTARY PUBLIC No ary
Setdk+YNE COUNTY u
North Carolina My commission expires In �-S- tea` I
My Commission Expires MARCH 25,2024