NCC241976_FRO Submitted_20240701

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
y
form and an acceptable erosion and sedimentation control plan have been completed and approved b
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form tothe
appropriate ro riate 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 Lot 610 Brookberry Farm-SFD Construction
CountyForsyth City or Township
Salem
2. Location of land disturbing activity:
402 Brookberry Farm Circle Latitude 36. 1060 Longitude 80. 3807
Highway/Street
3 Approximate date land-disturbing activity will commence:7/8/24
industrial, institutional, etc.):Purpose of development (residential, commercial, Residential
Total acreage disturbed or uncovered (includingoff-site borrow and waste areas): .35
5. g
6. Amount of fee enclosed: $ 100 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? YesYes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
NameJake Lugin E-mail [e-mail]
Telephone [phone] Cell # 336-469-2979 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Wishon & Carter Builders Inc 336-679-2031 336-679-4436
Name Telephone Fax Number
P.O. Box 1719 1412 West Main St.
Current Mailing Address Current Street Address
Yadkinville, NC. 27055 Yadkinville , NC. 27055
City State Zip City State Zip
10. Deed Book No. 003665 Page No. 02776 Provide
9 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.
Wishon & Carter Builders Inc 'akelu in wshon
J g @ ca rte r.co m
Name E-mail Address
P.O. Box 1719 1412 West Main St.
Current Mailing Address Current Street Address
Yadkinville, NC. 27055 Yadkinv
ille , NC . 27055
City State Zip City State
Zip
Telephone [phone] 336-
Fax Number 679-
4436

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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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.
R. Edward Carter President
Type or int name )/
Title or Authority
6/27/24
Sig ature Date
, a Notary Public of the County of Ycdkiy,
State of North Carolina, hereby certify that , Ec\v'cc S. 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� day of T e , 20 c `-1
DANA P WILES
NOTARY PUBLIC Notary
Se'f1kin County
North Carolina
Mycommission expires `
My Commission Expires :�pataci p a-�

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2021070317 00037
FORSYTH CO, NC FIE $26 00
IAT F OF NC REAL ESTATE EX TA
$292.00
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12 29-2021 09:13 03 AM
LYNNE JOI If ISOf I
REOIS1LR Of DFEDS
RY OLIVIA DOLE AR&r
BK: RE 3665
PG: 2776-2777
DRAFTED BY: Thomas T. Crumpler, Esquire PROBATE AND FILING FEE $ PAID
Excise Tax $ ' 3► • C 0
(NO TITLE SEARCH PERFORMED OR REQUESTED)
Tax Block 6576, Lot 610, Parcel Identifier No.: 5896-20-1322.00
Property address: 402 Brookberry Farm Circle, Winston-Salem, NC 27106
Mail after recording to: Grantee
Mail future tax bills to: Grantee
FORSYTH COUNTY, NORTH CAROLINA GENERAL WARRANTY DEED
THIS DEED made this 2rlda of e c, e .--- b e , 20 ZJ , by and between
GRANTOR GRANTEE
BROOKBERRY FARM, LLC UU ; Sh oln - Cam✓ +.ev 1 t ' $ , anc
a North Carolina limited liability company _
Address: PO Box 2736, Address: 402 Brookberry Farm Circle
Winston-Salem, NC 27102 Winston-Salem, NC 27106
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 Forsyth County, North Carolina and more
particularly described as follows:
Being known and designated as Lot 610, as shown on the plat of BROOKBERRY FARM,
Phase 8, as recorded in Plat Book 74, Pages 174, 175, and 176, in the Office of the
Register of Deeds of Forsyth County, North Carolina, reference to which is hereby made
for a more particular description.
The above described property is subject to the Declaration of Covenants, Conditions and
Restrictions for Brookberry Farm Single Family Homes as recorded in Book 2610, Page
899 and Master Declaration of Covenants, Conditions and Restrictions for Brookberry
Farm as recorded in Book 2610, Page 871 , and as subsequently amended.
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Original to . 6:!2::_Qb.L(4-1

The property herein conveyed does not include the primary residence of the Grantor.
AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances thereto
TO HAVEthat Grantor is seized
belonging to the Grantee in fee simple. And the Grantor covenants with the Grantee,
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: Easements, rights of way and restrictions of
record, if any, and current year ad valorem taxes.
IN WITNESS WHEREOF, the Grantor has set his hand and seal the day and year first above written.
BROOKBERRY FARM, LLC
a North C e• j1K- to P;/
diRri,
•
Graham Benn - , M-�'�ger
Forsyth County, North Carolina
I certify that the following person(s), either being personally known to me or proven by satisfactory evidence,
personally appeared before me this day, each acknowledging to me that he or she voluntarily signed the
foregoing document for the purpose stated therein and in the capacity indicated: Graham Bennett, Manager
of Brookberry Farm, LLC, a North Carolina limited liability company
Date: 1 I 3 1 �0 . I
C\A C o A it ,t (Printed name)
Notary Public
Commission Expires: I )- I )
My p
MICHAEL J. O'CONNOR
Notary Public-North Carolina
COUNTY OF GUILFQRD
My Commission Expires:_ ). I S 20 2 S