WQ0043033_Application (FTSE)_20211124

State of North Carolina
nWR Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 - FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Divislon of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number: (, (to be completed by DW ) Dept of EnvironMental Quality
All items must be completed or the application will be returned
Nov 2 4 2021
I. APPLICANT INFORMATION:
1. Applicant's name: City of Rocky Mount (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State.."County ® Municipal
3. Signature authority's name: William B. Kerr per 15A NUAC 02T .0106(bj
Title: Director of Public Works
4. Applicant's mailing address: P 0 Box 1180
City: Rocky Mount State: NC Zip: 27802-
5. Applicant's contact information:
Phone number: [phone] Email Address: brad.kerr(q_)rockymountnc.eov
II. PROJECT INFORMATION:
Raleigh Regional Office
❑ Privately -Owned Public Utility
❑ Other
1. Project name: Olde Mill Stream - Phase 2
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: WQ00 and issued date:
If new construction but part of a master plan, provide the existing permit number: WQ00_
3. County where project is located: Nash NC Dept ofEnvironmeptaI Qualit,
4. Approximate Coordinates (Decimal Degrees): Latitude: 35.946561 Longitude:-77.87574- z }
5. Parcel ID (if applicable): 383018310386 & 3833018311671 NOVti '1 2�2�
(or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION: Ralcigh Rcg1pnal Off ,
1. Professional Engineer: Ronald G. Fuentes License Number: 38604
Firm: Bartlett Engineering & Surveying, PC
Mailing address: 1906 Nash Street N
City: Wilson State: NC Zip: 27893-1726
Phone number: 252) 399-0704 Email Address: ronald(obartletteng.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Tar River Regional WWTP
Owner Name: City of Rocky Mount
Permit Number: NC 0030317
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different than WWTF):
1. Permit Number(s): WQ0033671 Downstream (Receiving) Sewer Size: 18 inch
System Wide Collection System Permit Number(s) (if applicable): WQCS00021
Owner Name(s): --Cily of Rocky Mount
FORM: FTA 04- l6 Page 1 of 5

VI. GENERAL REQUIREMENTS
l . If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
[:]Yes ❑No ZMA
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational, Agr"ment (FORM: DEVi been attached?
[--]Yes ❑No ®NIA
3. If the Applicant is a Home/Property Owners' Association, has an Operational Agreement ement i170 . HOAj been attached?
❑ Yes ❑No ®NIA
4. Origin of wastewater: (check all that apply):
® Residential Owned ❑ Retail (stores, centers, malls) ❑ Car Wash
❑ Residential Leased ❑ Retail with food preparation/service ❑ Hotel and/or Motels
❑ School I preschool i day care ❑ Medical i dental I veterinary facilities ❑ Swimming Pool /Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
❑ Businesses / offices I factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic/Commercial % Commercial
NC Dept of Environmental Quaigx
%Industrial {See 15A NCAC 02T .0103(201)
bIs there a Pretreatment Program in effect? []Yes ❑y Z 4 2921
6. Has a flow reduction been approved under 15A NCAC 02T .01 14(1)? ❑ Yes ❑ No
If ve3. provide a canv of flow rMnefinn annrnval latter
7. Summarize wastewater generated by project:
Raleigh Regional Off
Establishment Type (see 021.01140
Daily Design Plow A.n
No. of Units
Flow
Single Residential
360 gal/day
142
51,120 GPD
gal?
GPD
gall
GPD
gall
GPD
gal/
GPD
gall
GPD
Total
51,120 GPD
a See 15A NCAC 02T .01 14(b), d e I and e1(2) for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling; proposed unknown non-residential development uses; public access facilities located near high public use areas;
and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined
in G.S. 42A-4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.0114] shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project. 51,120 GPD (per I5A NCAC 02T .0114)
D Do not include future flows or previously permitted allocations
If permitted flow is zero, indicate why: Quality
El Pump Station or Gravity Sewer where flow will be permitted in subsequent PA&P t i�� &11oo 1selinel Q y
❑ Flow has already been allocated in Permit Number:
❑ Rehabilitation or replacement of existing sewer with no new flow expected
❑ Other (Explain):
NOV Z 4 2021
Raleigh Regional Office
FORM: FTA 04-16 Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers);
1. Summarize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
8
3,165
PVC
8
173
DI
18
1,626
PVC
18
1,136
DI
D Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section III contains information related to minimum slopes for gravity sewer(s)
➢ Oversizing lines to meet minimum slope requirement is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) -- 02T .0305 & MDC (Puma) Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: -�.
3. Design flow of the pump station: millions gallons per day (firm capacity)
4. Operational point(s) of the pump(s): _ gallons per minute at feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
6. Power reliability in accordance with 15A NCAC 02T _030. 5(h)f 11:
❑ Standby power source or pump with automatic activation and telemetry - 15A NCAC 02T .0305(h)(1)(13):
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility
Or if the pump station has an average daily flow less than 15,000 gallons per day:
❑ Portable power source with manual activation, quick -connection receptacle and telemetry - 15A NCAC 02T
,0305(h)(1)(C)
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry - 15A NCAC 02T .0305(h)(1)(C):
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant (draft agreement)
and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided
in the case of a multiple station power outage.
FORM: FTA 04-16 Page 3 of 5

NC neptofEnvironmental Qualit,
IX. SETBACKS & SEPARATIONS - (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations found in 15A NCAC 02T .0305(f) & (g) NOV 20210 Yes ® No
15A NCAC 02T.0305(Q contains minimum separations that shall be provided
Setback
Storm sewers and other utilities not listed below (vertical)
Water mains (vertical -water over sewer ini
Water mains
Reclaimed water lines (vertical - reclaimed over sewer
Reclaimed water li
mntal - reclaimed over sewer
24 inches
18 inches
10 feet
18 inches
2 feet
"Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water 100 feet
"Waters classified WS (except WS-1 or WS-V), B, SA, ORW, HQW, or SB from normal
high water for tide elevation) and wetlands (see item IX.2) 50 feet
*"Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches 10 feet
Any building foundation 5 feet
Any basement 10 feet
Top slope of embankment or cuts of 2 feet or more vertical height 10 feet
Drainage systems and interceptor drains 5 feet
Final earth
10 feet
36 inches
➢ 15A NCAC 02T.030 ) contains alternatives where separations in 02T.0305(fl cannot be achieved.
➢ "Stream classifications can be identified using the Division's N[: Surface Water Classifir.ations webpag e
➢ If noncompliance with 02T.0305(f) ori, see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) ❑ Yes ® No
➢ See the Division's draft separation requirements for situations where separation cannot be meet
➢ No variance is required if the alternative design criteria specified is utilized in design and construction
➢ As built documents should reference the location of areas effected
3. Does the project comply with all setbacks found in the river basin rules per 15A N AC 02B .0200? ® Yes []No
➢ This would include Trout Buffered Streams per 15A NCAC 2B.0202
4. Does the project comply with an individual 404 Permit or any 401 Certifications? ® Yes [:]No
➢ Wetland -related permits shall be requested, obtained, and adhered to for projects that impact wetlands or surface waters
➢ Information can be obtained from the 401 & Buffer Permitting Branch
5. Does project comply with 15A NCAC 02T.0101cn) (additional permits/certifications)?
® Yes ❑ No
Per 15A NCAC 02T.0105Lc)L61, directly related environmental permits or certification applications are being prepared, have
been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion and
sedimentation control plans, stormwater management plans, etc.).
6. Does this project include any sewer collection lines that are deemed "high -priority?"
Per 15A NCAC 02T.0402, "high -priority sewer" means "any aerial sewer, sewer contacting surface waters, siphon, or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
❑ Yes ® No
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and inspections
documented per 15A NCAC 02T.0403(a)(5) or the permitee's individual System -Wide Collection permit.
FORM: FTA 04-16 Page 4 of 5

X. CERTIFICATIONS:
Does the submitted system comply with I5A NCAc 0211, the Minimum [ esu.sk Critena for the P'ennitllttl of Punii+ Siatp+,
and Force Mgut tlglc t ve�rsignl and the cmy Scwc� rnimum fksi •iI rjlcila date iopj as applicable?
® Yes ❑ No
If No, complete and submit the Variance/Alternative Design Request application (VADC 10-14) and supporting documents for
review. Approval t Is ryoulMdo al of the Fast Track Application and ouppoigng dqcwnents
2. Professional Engineers Certification:
attest that this application for
(Professional Engineer's name from Application Item M.1.)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans, specifications,
engineering calculations, and all other supporting documentation to the best of my knowledge. I further attest that to the best
of my knowledge the proposed design has been prepared in accordance with the applicable regulations, Gravity Sewer
Minimum Design Criteria for Gravity Sewers (latest version), and the Minimum Design Criteria for the Fast -Track Permitting
of Pump Stations and Force Mains (latest version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation.
North Carolina Professional Engineer's seal, signature, and date:
3. Applicant's Certification per 15A NCAC 02T .0106(b):
I, G�I�II+►+ re- c1v2 6UiL b.7v attest that this application for
(Signature A�hortty's name &tit from Application Item 1.3.)
him been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of
this application are not completed and that if all required supporting documentation and attachments are not included, this
application package is subject to being returned as incomplete. I understand that any discharge of wastewater from this non -
discharge system to surface waters or the land will result in an immediate enforcement action that may include civil penalties,
injunctive relief, and/or criminal prosecution. I will make no claim against the Division of Water Resources should a condition
of this permit be violated. I also understand that if ail required parts of this application package are not completed and that if
all required supporting information and attachments are not included, this application package will be returned to me as
incomplete.
NOTE — In accordance with General Statutes 1 4 3 - 215,6A and 143-215.6R, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to S25,000 per violation.
Signature: Date:
FORM: I`f A 04-16 Page 5 of 5

0 State of North Carolina
DD Department of Environmental Quality
.WE% Division of Water Resources
Division of Water Rcsourc es Floe' Tracking/Acceptance for Sewer Extension Applications
(FTSE 04-16)
lintity Requesting Allocation: City of Rocky Mount
Project Name for which flow is being requested: Old Mill Stream Phase If
Alone than one FTSE ► tqv be required for a single preyect if the o+swer of the 1P11'TI' is nat responsible for all pump
stations along the route of the proposed waste►varer flow.
I. Complete this section only if you are the owner of the wastewater treatment plant.
a, WWTP Facility Name: Tar River Regional
b, WWTP Facility Permit #: NCO030317
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
li. Percent of permitted flow used
A11 flows are in MGD
21.00
0.6326
10.83
0.05
11.512
54.81%
11. Complete this section for each pump station you are responsible for along the route of this
proposed wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A) (B) (C) (1))=(B+C) (F)=(A-1))
Design Obligated,
Pump Average Daily Approx. Not Yet Total Current
Station firin flow" Current Avg. 'Tributary Flow Plus
(Name or Capacity, * (Firm ; pl), Daily Flow, Daily Plow, Obligated Available
Number) MGD MGD MGD MGD Flow capacity"••
97 Lilt St 30 12 6.5 0.6326 7.133 4.867
Old Mill 1.05 0.42 0.363 0 0.363 .057
* The Firm Capacity of any pump station is defined as the maximum pumped flow that
can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking
factor (pt) not less than 2.5.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer): Tar River Regional
Dox ntstrcam Permit Number; NC 0030317
Page l of 6
FTSF- 04-16

x Ill. Certification Statement:
l William Brad Kerr certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the
receiving wastewater treatment facility and that the now from this project is not anticipated to
cause any capacity related sanitary sewer overflows or overburden any downstream pump station
en route to the receiving treatment plant under normal circumstances, given the implementation of
the planned improvements identified in the planning assessment where applicable. This analysis
has been performed in accordance with local established policies and procedures using the best
available data. This certification applies to those items listed above in Sections I and it plus all
attached planning assessment addendums for which I am the responsible party. Signature of'this
form indicates acceptance of this wastewater flow.
Vgning Oridal
f� lrS -z%
Date
Page 2 of 6
FTSE 04-16

1906 Nash Street North Wilson, NC 27893-1726
Phone: [phone]'+04 Fax: [phone]
wwwbartielt.us.com
November 22, 2021
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
Raleigh Regional Office
1628 Mail Service Center
Raleigh, North Carolina 27699-1628
Reference: Fast Track Application for Gravity Sewers
Private Sewer Extension
Olde Mill Stream -Phase 2
Rocky Mount Township
Nash County, North Carolina
To Whom It May Concern:
NC Dept of Environmental Quality
Nov 2 4 2021
Raleigh Regional Office
Enclosed for your review and approval are two (2) copies of the following items related to the
above referenced project:
■ Fast Track Application for Gravity Sewers
■ Flow Tracking / Acceptance Form
■ USGS Topographic Map
■ Firm Map & Deed
This request is for an 8" gravity sewer system tying into an existing outfall sewer with an 18" gravity
pipe. This system serving 142 Lots of Phase 2 of the Olde Mill Stream Subdivision located along S.
Halifax Road (SR 1544) within the City of Rocky Mount.
Also enclosed is the $480.00 sewer permit application fee. Should you have any questions or
require further information during your review, please let us know.
Respec y
Steve iverio
Project Manager
Enclosures
P- PROJECT F1LMOI& Mill Stream Phase RPamitting�Sanitary SewcrUO 042 NCDENR Cover Lettn d,ti

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Page 1 of 4
This ratifies that there It no ddi —`�
the Nash Cou nquent ad va:orrtn rrai Wuk
"tY 7bx Collenor is charaw with colle l Wes, which
Mn Number 383 O 14 diet are a lien on:
This isnot a 3t:tel+u i 3 3ot83toSg`
�erarm-tiort first this Nash Count T k
maehas this Decd desc • Y ax Depertrt>ept Pin Number
rrptioa.
Tax Collector, Deputy Tax Collector, T fie' f4
Tax Clerk
Tax Lot No.
Verified by:
zz
Mail after ruing to: Mt M to f 5-hpal
This instrument drawn by: T6Ms4 4:. �hA
Brief description for the Indent: 2. TItAcrS
Nash County, NC, Parcel Nos.
NORTH CAROLINA
THIS DEED made this � day of -_
GRANTOR
The UNCG 80eelleme Foundation, Inc., a
North Carolina non-profit corporation,
as TRUSTEE.
C/o Office of Business Affairs
University of North Carolina at Greensboro
PO Box 26170
Greensboro, NC 27402-6170
NOW In the appreprbate block for
character of entity, e.g. eo:poratton or
nrl
Doc ID: 004204040004 TVDe: Cap
Recorded: o6/04/2006 at 03:06:22 PM
Fes tUtt: tt.126.00 Paps I of 4
Fateles Tarr: I.200.00
Nae County North Caroline
Barbara V. Gasser Reaiater of oesds
oK2 is2 Po77o-773
cel Identifier No.
on the day of ,
7)"Awcx MO, SM
18311671U & 383018310386U
WARRANTY DEED
20_ = ► by and between
GRANTEE:
Hodge & Morris, LLC, a
North Carolina Limited Liability Company.
1708 Trawick Road, Suite 209
Raleigh, NC 27604
Party: name, address4 and, ff appropriate,
Book: 2162 Page: 770 Seq. 1

Page 2 of 4
1.0.0. The designation Grantor and Grant
heirs, successors, and assigns, and shall
neuter as required by context.
2.0.0. --, that the Gray
Grantee, the receipt of which is hereby a
transfer, grant, bargain, and convey in fee
parcels of land situated in Oak 14ml Toe
more particularly described as follows;
as used herein shall include said parties, their
singular, plural, masculine, feminine, or
for good and valuable consideration from the
igoed, by these presents does hereby sell,
unto the Grantee all those certain lots or
Nash Coaaty, North Carolina, and each
No. 1: BEGINNING at a point in the ter of the Halifax Road, also center of bridge
across Maple Creek; thence up the center of adn Creek, N. 12' S5' W. 217 feet, N. 35- 30' W.
270 feet, N. 55' W. 239 feet, N. 63. 40, W. 19 feet, N. Si° w. 183 feet, S. 82' 45' W. 236 feet,
S. 54- SO' W. 173 feet, N. 73. 40' W. 170 feet, N. 70' 25' W. 253 feet, N. 28' 45' W. 191 feet, N.
37- I0' W. 108 feet, N. 62' 15' W. 123 feet, N. 53' IS' W. 232 feet, N. 80' 40' W. 195 feet, N. 86'
40' W. 236 feet, S. 86' 30' W. 201 fieeet, to Mose Whitley's corner, marked by a stake on the
north side of the Creek and by sweetgum and hornbeam pointers; thence along Mose Whitley's
line N. 7' E. 705 feet to an iron stake, Mrs. 011ie Whitley's corner, pine pointers; thence along
Mrs. Mollie Whitley's line S. 89' 25' E. 27961feet to the center of the aforesaid Halifax Road,
masked by a stake on the west side thereof; ence along the center of said Halifax Road, S. 40
45' W. 327.5 feet, S. 6' W. 305 feet, S. 00' 30 W. 467 feet, S. 6- 45' W. 160 feet, S. 17. 10, W.
568 feet, to the BEGINNING; containing 7 .1 acres, according to 'Map of Farm of J. M.
Johnson' made by E. L. Hurley, C. E., on Mach 5, 1937.
Parcel No. 2: Farm No. 5 on plat of property
as The Whitley Place as surveyed and plotte
recorded in Book 208. Page 285, Nash Coun
at a point in the western line of old Halifax R
Chapman & F. W. Thorp Farm property; the
north 12' 40' west 359 feet to a stake; thence
2650 feet to its southwest corner; thence se
thence south 05' 50, west 136 feet to northwe
line of tract No. 6 2782 feet to the BEGINNIN<
Whitley (now deceased) and wife, Mollie E. Wi
by deed, dated December 22, 1913, and reco:
148, by Cleo. B. Chapman and wife, Bia T. C
tract of land conveyed by Fred W. Thurston I
Summeriin by deed dated June 30, 1954, i
ash]'.
3.0.0. tercel No. I hereinabove descr
from J. M. Johnson and wife recorded in Boc
acquired by Grantor by deed dated January
Nash County Registry; in addition, said pn
Assessor's Parcel Number 3830183116711J.
formerly owned by Mrs. Robert Mayo, and known
i by James A. Clark which said plat or map is
y Registry, containing 24.94 acres, BEGINNING
.ad northeast corner of tract No. 6 of the Cleo. B-
ice north 03' 05' east 49 feet to a stake; thence
with the southern line of lot or tract #4 westerly
nth 09° 00' west 270 feet to a lightwood stake;
it corner lot No. 6; thence easterly with northern
; and BEING the same land conveyed to W. J. R.
Itley (who is now married to Fred W. Thurston),
ded in Nash County Registry in Book 212, Page
kapman, and F. W. Thorp. BEING the identical
nd wife, Mollie E. Whitley Thurston to Clyde E.
.corded in Book 598. Page 531, Nash County
W was conveyed to Clyde E. Summerlin by deed
477, Page 403, Nash County Registry; and was
1976, and recorded in Book 978, Page 273,
F is further identified by Nash County Tax
H No. 2 hereinabove described was acquired
by Grantor by deed dated July 30, 1975, and' recorded in Book 971, Page 659, Nash County
Registry; in addition, said property is further
BOOK2162PAUE
by Nash County Tax Assessor's Parcel
Book: 2162 Page; 770 Seq:2

Page 3 of 4
Number 383018310386U. Parcels Nos. 1 & 2
day of August, 2005, and recorded
Registry, North Carolina.
4.0.0. TO HAVE AND TO BOLD said
belonging to the Grantee in fee simple.
re both acquired by Grantor by deed dated the
Book . Page , Nash County
with all privileges and appurtenances thereto
5.0.0. And the Grantor covenants with the Grantee, that Grantor is seised of the premises in
fee simple, has the right to convey the same ii fee simple, that title is marketable and free and
clear of all encumbrances, and that Grantor warrant and defend the title against the lawful
claims of all persons whomsoever except forteemoeptions hereinafter stated.
6.0.0. Title to the property hereinabove de
restrictive covenants, and rights of way of re
and made a part of this conveyance, AND the
7.0.0. IN WITNESS WHEREOF the Gran
corporate, has caused this instrument to be
officers and its seal to be hereunto affixed
year first above written.
PMm
The UNCG Excellence Foundation, Inc.,
By:
Phillip A. Richman, Treasurer
ATTEST: ����
art, secretary
gDOx2162m.17i
d is subject to all easements, restrictions,
which are incorporated herein by reference
ing stated emmeptions: NONE.
• has hereunto set his hand and seal, or if
toed in its corporate name by its duly authorized
authority of its Board, of Directors, the day and
VM ONLY)
. 4SEAL)
(SEAL)
— (SEAL)
(SEAL)
Book: 2162 Page: 770 Seq: 3

* page 4 of 4
IM MLAM MK OWLT)
SEAL. - STAMP NORTH CAROLINA, County:
1, a Notary Public of the County and State aioreeeid, oar* that
Grantor, peraana ly appeared before me thia day and acknowledged the execution of the
forgping instrument. Witness my hand and official stamp or sea[, this day of
My Commission expires: Notary Public
PMWACKMKONLYI
•,�� , NORTH CAROLINA, sty'
O�r, �••'� ! ►/• ' N., k, a Notary Public of the County and State of moid, oerpfy that
;.i• i`;;� i iy' :. t3TR��"'!NCG
raonally came before me thi¢ day and acknowledged that she/be is Secretary of THE
EXCELLENCE FOUNDATION WC., a North Carolina. corporation, and that by
h.
r'�.: •'gig ;" ;�!��:• � `•Ns' s rauthu* duly given and as the act of the corporatkm, the fOsegoing instrument was signed
+�����r,��1�l " " ►9,�*�``?�:,�• in its name by its td R sealed with i%s alrporate reel, and
by her/him as its Secretary. Witness my hand and official stamp or seal, this
day of
my Comtmsaian expires; � 2 4' O.S otsry kPtrbtic
the foregoing C r iScate(s) or
is/are oerdfied to be conwL This instrument and this certificate are duly registered at the date and time and in the
and shown an hereof.
REGISTER pF DSEDS F�(]R COUNTY
BY Deputy/Assistant _ Regular of Deeds
I Aoo.00 Aw.
-23, o0
162na M
Book: 2162 Page: 770 Seq:4