NCC241373_MODIFICATION Supporting Doc (ADDL LOTS)_20260317 (2)

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: WILLIAMS RUN LOTS 51-53, 106, 108-110, 117, 118
*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).
Is Project ARPA Funded ARPA Project Name ARPA Project#
No
Is Project SL 2023-134 Funded SL 2023-134 Project Number
No
2. Location of land-disturbing activity: County: Nash City or Township: Bailey
Highway/Street: BUMBLE BEE CT Latitude: 35.824409 Longitude: -78.07071
3. Approximate date land-disturbing activity will commence: 05/29/2026
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.62
6. The application fee of $119.00 per acre (rounded up to the next acre) is assessed without a ceiling amount
(Example: An 8.10 acre application fee is $1,071).
7. Has an erosion and sediment control plan been filed? No
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: MATT GOODEW E-mail Address: [e-mail]
Phone: [phone] Mobile: [phone]
9. Landowner(s) of Record:
Landowner(s)of Record
Name Email Business Phone _ Mobile Phone
C.T.WILLIAMS CORPORATION [e-mail] 252-205-1151 252-205-1151
Physical Address Mailing Address
3303 Sunset Ave STE H Rocky Mount,NC 27804 3303 Sunset Ave STE H Rocky Mount, NC 27804

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).
Primary Financially Responsible Party
Company Name Email Business Phone Mobile Phone
NVR, INC. [e-mail] 919-987-1930
Physical Address Mailing Address
11700 Plaza America Dr Suite 500 Reston,VA 20190 11700 Plaza America Dr Suite 500 Reston ,VA 20190
Additional Financially Responsible Parties
No additional financially responsible parties were entered on the application.
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 Information
Name Email Business Phone Mobile Phone
CORPORATION SERVICE COMPANY(Tyler Yates, [e-mail] 800-927-9800
ex 66899)
Physical Address Mailing Address
2626 Glenwood Ave STE 550 Raleigh,NC 27608 2626 Glenwood Ave STE 550 Raleigh, NC 27608
(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:
North Carolina Agent Information
Name Email Business Phone Mobile Phone
Physical Address Mailing Address
Engineering/Consulting Firm Information
Name Email Business Phone Mobile Phone
MORRIS&RITCHIE ASSOCIATES, INC. Daryn.Allgeier mragta.com 410-515-9000 443-981-9172
Physical Address Mailing Address
3445 Box Hill Corporate Center Dr Suite A Abingdon,MD 21009 3445 Box Hill Corporate Center Dr Suite A Abingdon, MD 21009
Additional Details
1. Stream Classification: NSW: Nutrient Sensitive Waters, WS-III: Water Supply III
2. Was Express Review Requested: Yes
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.