NCC222256_FRO Submitted_20220620

FINANCIAL RESPONSIBILITYIOWNERSHIP 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
2.
3.
Project NameCobb Farm Subdivision Phase II
Location of land -disturbing activity: County Rockingham City or Township Reidsville
Highway/Street Country Lane (SR 2453) Latltude(decimaldegrees) 33.0341 Long itude(decimal degrees) 62-1444
Approximate date land -disturbing activity will commence: 07/05/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 1.60
6. Amount of fee enclosed: $700 . 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. (2 Acres " $100 + 2 Acres " $250 (Express Review Fee) =$700)
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
A
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameTony Johnson E-mail [e-mail]
Phone: Office # 336-587-3673 Mobile # [phone]
9 Landowner(s) of Record (attach accompanied page to list additional owners)
CF Farms, LLC 336-587-3673
Name
3714 Alliance Drive, Suite 300
Current Mailing Address
Greensboro, NC 27407
City State Zip
Phone: Office #
3714 Alliance Drive, Suite 300
Current Street Address
Greensboro, NC
City State
336-587-3673
Mobile #
27407
Zip
10. Deed Book No.1467 _ Page No.399 Provide a copy of the most current deed

Part E$.
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).
CF Farms, LLC [e-mail]
Company Name
3714 Alliance Drive, Suite 300
Current Mailing Address
Greensboro, NC, 27407
E-mail Address
3714 Alliance Drive, Suite 300
Current Street Address
Greensboro, NC, 27407
City State Zip City -
Phone: Office # 336-587-3673 Mobile # [phone]
State Zip
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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
FEI Consulting_
Engineering firm or other consultant
Brent Nesom
Individual contact person (type or print)
bnesornAfeiconsultina.com
E-mail Address
336-544-6421
Phone: Office # Mobile #
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.
`to n r . Jol, n-5e2::"
Type or print name Title or Authority
SiTnatur �� Date /
---- -------3------------------------------------------ — — ---------------------------------------------
--
I a Notary Public of the County ofION
U
State of North Carolina, hereby certify that _ TON b -:EOWSOV1 appeared personally
before me this day and being duly sworn acknow dle g d that the above form was executed by him/her.
Witness my hand and notarial seal, this H day of _150ytift, , 20 22
J—V
Notary
Seal My commission expires1
SUZANNE M THOMASSON
NOTARY PUBIC
GUILFORD COUNTY, NC
MYC&W*Sbn Z-0 -Z OZ

PAGE
4 111
IYn'I yaB (9)
52028
Filed
Rockingham County, NC
Rebecca B. Cipriani, Register of Deeds
12/05/2013 10:31:43 AM
Fee Amt: $26.00 NC Excise Tax: $600.00
CATINIA E. WINCHESTER
NORTH CAROLINA GENERAL WARRANTY DEED
Revenue Stamps: $600.00
Mail after recording to -GRANTEE-
This instrument was prepared by Joseph G. Maddrey
Brief description for the Index
THIS DEED made this 1_
GRANTOR
Clark M. Holt and wife
Marguerite H. Holt
Address: 1008 Ridgwood Drive
Reidsville, NC 27320
2013. by and between
GRANTEE
Cobb Family Farms, LLC
Address: 1318 Winterberry Drive
Reidsville, NC 27320
Enter in appropriate block for each party: name, address, and if appropriate, character of entity, e.q, corporation or partnership
The designation Grantor and Grantee as used herein shall include said parties, their heirs, successors,
and assigns, and shall include singular, plural, masculine, feminine or neuter as required by context.
WITNESSETH, that the Grantor, for a valuable consideration paid by the Grantee, the receipt of which
is hereby acknowledged, has and by these presents does grant, bargain, sell and convey unto the
Grantee in fee simple, all that certain lot or parcel of land situated in Rockingham County, North
Carolina and more particularly described as follows:
See Exhibit A Attached.
This property does does not include the primary resident of the Grantor(s).

BK 1467 PG 400 DOC# 520281
The property herein above described was acquired by Grantor by instrument recorded in
A map showing the above described property is recorded in Plat Book , page
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances
thereto belonging to the Grantee in fee simple.
And the Grantor covenants with the Grantee, that Grantor is seized of the premises in fee simple, has
the right to convey the same in fee simple, that title is marketable and free and clear of all
encumbrances, and that Grantor will warrant and defend the title against the lawful claims of all persons
whomsoever except for the exceptions hereinafter stated.
Title to the property hereinabove described is subject to the following exceptions:
Taxes for the current year, rights -of -way of public highways and roads and public
utilities, easements and restrictions of public record.
IN WITNESS WHEREOF, the Grantor has hereunto set his hand and seal, or if corporate, has
caused this instrument to be signed in its corporate name by its duly authorized officers and its seal to
be hereunto affixed by authority of its Board of Directors, the day and year first above written.
(USE BLACK INK ONLY)
(�M[SEAL)
Clark M. Holt
(SEAL)
C'lar�k I. Holt by and through his attorney
In fact Marguerite H. Holt
[SEAL)
Marg Mte H. Holt
SEAL -STAMP NORTH CAROLINA, County.
I,_ _ a Notary Public of the County and State aforesaid,
�•`'� �p`FtEIV S . ,certify that Clark M. Holt and Marguerite H. Holt, personally appeared before me
to O T v� This day and acknowledged the execution,%f the foregoing Instrument. Witness
z a. �$� stay hand ff and ocial stamp or seal, this d y of 2013,
I G gy commission expires:
'c��M •'G% No Public
,, 00LIN�'S.t' r/
++1tf[JJ1%+"
STATE OF NORTH CAROLINA, Rockingham County
I, } a Nosary Public in and for Rockingham County and said State, do hereby certify that
Marguerite H. Holt, Attomey-in-Fact For Clark M. Holt, personally appeared before me this day, and being by me duly
sworn, says that she executed the foregoing and annexed instrument for and in behalf of Clark M. Holt and that her
authority to execute and acknowledge said instrument is contained in an instrument duly executed, acknowledged and
recorded in the Office ofthe Register of Deeds, in the County of Rockingham, State ofNorth Carolina, on the 22' day
of February. 2012, Book 1429 ,Page l 156 and that this instrument was executed uric�Kttn t rgi;ue of the authority
given by said instrument granting him/her Power of Attorney. ��t K , t,
witne. my hand and official seal this th0-F'' day of December, 2013. S% N a� T��
tiQ
N014 Public
My Commission Expires: tr\ _� Le 1 I _�U ^ �
Cit t ���,�'rJ 'm5i``rz,

BK 1467 PG 401 DOC# 520281
EXHIBIT A
Tract I: Being the 36.992 Acre tract (0.552 within the Right of Way for net of 36.440 Acres) of
land abutting Country Lane as shown on the Survey for Marc L, Cobb dated November 19, 2013
by Obie M. Chambers and Associates recorded in Map Book 72, Page 74. Rockingham County
Registry.
Tract 2: All right, title and interest to the property whose (A) North line is the extension of the
terminus of Southern half of Country Lane (designated "End Pvment and NC DOT Maint." on
the said Cobb Plat) to the east property line of Tract 1, (B) East line being the terminus of
Country Lane (designated "End Pvmnt and NC DOT Maint." on the said Cobb Plat), (C)South
line being the South fine of Country Lane extended to the east property line of Tract 1 (D) and
the West line being the East property line of "tract t.
Tract 3: All right title and interest to the easement reserved over the area south of the line
designated as "Right of Way Easement' as more particularly described in that deed recorded in
Book 800, Page 984.
It is the intent of the Grantors to convey to the Grantee all the remaining interest owned by
Grantors in that tract of land described in Book 511, Page 276.

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
City
Deed Book No.`
Landowner 3 of Record
Name
Current Mailing Address
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed
------•--- A -s ^----J.
Name
Current Mailing Address
City
Deed Book No.
Name
Current Mailing Address
City
Deed Book No.
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part 8 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 #