NCC233700_FRO Submitted_20231215

Check if this protect is ARPA ft;ncled
tari1 o cep fthe Letter of intent to Fond
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDI ENTATION 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 (IL'(-eh
rca+ -Icirbur Lcb 10 and lit I I
this oreiect if7VO!VeS 4n3eilcaki Rescue Plan Act ARPAti fureis list Projeet Narhe cir Project
Nuinher SRP-D,APP-0121) beiew utleiGr,:vhich you erste appro me for ft;17C;ing throtlgt' the
r;qvisioti of Water Infra,,,Irtictrt,o
c)Kt i
2. Location of land-disturbing activity: County lICI Ii-)E1 I City or Township LOYCIOALI I op •
L-75'3 2 •
Highway/Street , Latitude(deci .9,,F5Je1laati , ;,
mal degrees) L.01191LUue(declmal degrees)--- s! I 37314,00
DnY
3. Approximate date land-disturbing activity will commence: alci I . 00/3
4. Purpose of development(residential, commercial, industrial, institutional, etc.): RCSi Oeitik-I
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): I CLIC/
6. Amount of fee enclosed: $ c0O I 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 El Enclosed ERI No El
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name 5 halcC,Yl i ) S I ha Es )
E-mail Address 3\101-(5111 anc,j6 LC(nail
Phone: Office# rAJ Mobile# / eiko 5(70-0 .0
9. Landowner(s)of Record (attach accompanied page to list additional owners):
jakq Cc( 51(larcAft V5 atict lei/4) 5(70-0169
Name Phone: Office# Mobile#
8F)70 R+ )cAm
Current Mailing Address Current Street Address
Brockk)ctu
ftEf )6(1A c__
City State Zip City State Zip
10. Deed Book No. , Page No. Eio EE 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).
1,
,__)G4 )11 apc1 3hco-ort it ncs circacindic e c MCA i( CCri
A
Company Name E-mail Address
6?)176 c)
)0y7)
Current Mailing Address Current Street Address
BrOC<L0a L1 -pm Jam
City State Zip City State Zip
Phone: Office# Mobile# ) r3- 561
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
)14 A A
Current Mailing Address Current Street Address
tiq
City State Zip City State Zip
Phone: Office# Mobile# r (14
rv.tR
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:
Dajc(r) Grcolf 8 H:35ocick-c5,111c + rdc rrrF1 CO1
Name of Registered Agent E-mail Address
,51'rqcni-at Sulk dc a )ckiiie.
Current Mailing Address Current Street Address
.3-"CCI-e--5Y I ( (lc 61PL)d5
City State Zip City State Zip
Phone: Office# (7(4 C(c6.-1-7(? Mobile#
tiatfho.) jorcicqh
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.
j-
Co pany 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 aforney-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.
S%fin and D harcl1. I I 0GJr)er5
Type o- print name Title or Authority
hcam_ o13( 19,
ignature Date
IRcianLi �Z �1<t«(� r)e
—, a Notary Public of the County of `��
State of n. = hereby certify that\vh� R N� v- �r 5 k��J",rx VJ 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 30 day of G c , 202 3
L ��
Commonwealth of Pennsylvania•Notary Seal Notary
Rodney R.Shields,Notary Public
Jefferson County c 2 7c Z"
My commission expires September 12,2026 My commission expires t
Commission number 1151165
?;lember,Pennsylvania Association of Notaries

This Document eRecorded: 08/14/2023 11:04:47 AM
Fee: $26.00 Tax: $0.00
Caldwell County, North Carolina
Wayne L. Rash, Register of Deeds
COS INATION DEED
Excise Tax: $0.00
Parcel ID: 2795601565 and 2795602627
Mail/Box to:—_ Grantee
I Prepared by: Law Offices of Amos&Kapral,LLP, 1331 N.Center Street,Hickory,NC 28601
WITHOUT TITLE E NATION OR CLOSING _
Brief description 5753&5755 Lake Pointe Dr.,Grande Falls,NC 28630
Lfor the index:
THIS GENERAL WARRANTY DEED("Deed")is made on the w day of August ,20 23 ,by and between:
GRANTOR I GRANTEE
John R.Hines,Jr.and wife,Sharon D.Hines 'John R.Hines,Jr.and wife,Sharon D.Hines
8870 Rt 28 North 870 Rt 28 North
lBrockway,PA 15824 Brockway,PA 15824
Enter in the appropriate block for each Grantor and Grantee their name,mailing address,ana if appropriate,state of organization and
character of entity,e.g.North Carolina or other corporation,LLC,or partnership. Grantor and Grantee includes the above parties and
their respective heirs,successors, and assigns, whether 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 r~_.~t,bargain,sell and convey unto the Grantee in fee simple,all that certain lot,parcel of land or condominium
unit situated in the Lovelady Township,Caldwell County,North Carolina and more particularly described as follows:
SEE EXHIBIT"A"ATTACHED HERETO AND MADE APART HEREOF.
THE PURPOSE OF THIS DEED IS TO COMBINE THE LOTS/PARCELS INTO ONE LOT/PARCEL.
Prepared by the Law Offices of Amos & Kapral, LLP. The attorneys who prepared this instrument have not performed a title
examination of the subject realty and therefore make no opinion or warranty as to the quality of title nor have said attorneys participated
in any real estate closing involving this instrument. The parties to this instrument agree they have reviewed,understand and agree to
terms of this instrument, and that the attorney/client relationship between the clients) ordering and paying for this instrument and
attorneys preparing this instrument is strictly limited to the instrument's preparation.
All or a portion of the Property was acquired by Grantor by instrument recorded in)3ook 1973,Page 1495&Book 2009,Page 898.
All or a portion of the Property 13 includes or Ri does not include the primary residence of the Grantor.
A map showing the Property is recorded in Book 34,Page 80.81.
NC Bar Association Real Property Section Form No. 3®Revised 02/2021
Printed by Agreement with the NC Bar Association
Submitted electronically by "Law offices of Amos & Kapral, LLP"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Caldwell County Register of Deeds.

8=0i 8 %.4. gzra erne"kaa,"ks0 I 1 UV 80 Ur CI 84,0"ad'tot°
TO HAVE AND TO HOLD the Property and all privileges and appurtenances thereto belonging to Grantee in fee simple. Grantor
covenants with Grantee that Grantor is seized of the Property in fee simple.Grantor has the right to convey the Property in fee simple.,
title to the Property is markitile and free and clear of all encumbrances,and Grantor shall warrant and defend the title against the
lawful claims of all persons whomsoever,other than the following exceptions:
All matters of record.
IN WITNESS WHEREOF, the Grantor has duly executed this North Carolina General Warranty Deed, if an entity by its duly
authorized representative.
r4r4
Nam;111 oiont R.Hines,Jr. • Entity Name
j)a-117CD, By:
Name:Sharon D.Hines Name:
Title:
Name:
By:
Name:
Name:
•
STATE OF e ,COUNTY OF ...it
• 48 n ,a Notmy of the above state and county,certify that the following person(s)
personally appet before me on the 7 day of August ,20 23 each acknowledging to
me that he/she/they signed the foregoing document,in the c u'achy represented and identified therein(if any):
John XL Hines,Jr.and Sharon D.Hines •
Affix Notary Seal/Stamp . /
' •
---
Commonwealth of Pennsylvania-Notary Seal Notary Pub (0 cial Signe
Nicholas Gordon,Notary Public My commission expires: it/f
Jefferson County
My commission expires February 5,2024
Commission number1304688
Member,Pennsylvania AeSOCIatiOn of Notaries
2
NC Bar Association Real Property Section Form No, 30 Revised 02/2021
Printed by Agreement with the NC Bar Association

II % 160'kese•ass•I• I Is0 *40 Iher•••19 led
Exhibit A
Legal Description
BEING all of Lots 10 and 11 of Waterfront Harbor-Phase 2 as shown on a plat recorded in Plat Book 34,at P t es
80-81,Caldwell County Public Re::• ,said pint and the record thereof being referenced and incorporated herein
for greater certainty Qf description.
THE PURPOSE OF THIS DEED IS TO CO n i•LOTS/PARCELS ABOVE INTO ONE LOT/PARCEL.