NCC242429_FRO Submitted_20240812

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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 NCGO1 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 Name Union Grove Road and Hedge Road Improvements
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County Davidson City or Township Arcadia
Highway/Street Union Grove Road and Hedge Road LatitUde(decimal degrees) 35.9778 Longitude(decimal degrees)-80.2712
3. Approximate date land-disturbing activity will commence: 08/01/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Roadway improvements
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.32
6. Amount of fee enclosed: $ 200 . 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 2 No E
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kat Lyons E-mail Address [e-mail]
Phone: Office# 336-628-1414 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT 704-630-3200
Name Phone: Office# Mobile#
4770 Sout Main Street 4770 Sout Main Street
Current Mailing Address Current Street Address
Salisbury, NC 28147 Salisbury, NC 28147
City State Zip City State Zip
10. Deed Book No. n/a Page No. n/a 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).
Leoterra Development Inc. [e-mail]
Company Name E-mail Address
110-A Shields Park Dr 110-A Shields Park Dr
Current Mailing Address Current Street Address
Kernersville, NC 27284 Kernersville, NC 27284
City State Zip City State Zip
Phone: Office# 336-628-1414 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)

(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.
Christopher Lyo President
Type or pri tuna Title or Authority
'I/2.3
Sig Date/
D a Sandknop , a Notary Public of the County of Guilford
State of North Carolina, hereby certify that Christopher Lyons 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 141 day of Ton"( 20 4,13
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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:
Michael H. Sykes and Donna H. Sykes
Name Phone: Office# Mobile#
2853 Union Grove Rd 2853 Union Grove Rd
Current Mailing Address Current Street Address
Lexington, NC 27295 Lexington, NC 27295
City State Zip City State Zip
Deed Book No. 1326 Page No. 0853 Provide a copy of the most current deed.
Landowner 3 of Record:
Peirre Camile Goyette Jr. & Brandy Nicole Goyette
Name Phone: Office# Mobile#
1441 Hedge Road 1441 Hedge Road
Current Mailing Address Current Street Address
Lexington, NC 27295 Lexington, NC 27295
City State Zip City State Zip
Deed Book No.2486 Page No. 0351-0352 Provide a copy of the most current deed.
Landowner 4 of Record:
Donald C Pollard & Jean G Pollard
Name Phone: Office# Mobile#
2775 Union Grove Rd 2775 Union Grove Rd
Current Mailing Address Current Street Address
Lexington, NC 27295 Lexington, NC 27295
City State Zip City State Zip
Deed Book No. 1863 Page No. 0858-0859 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.