NCC222093_FRO Submitted_20220606

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 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 and/or fax information
unavailable, place NIA in the blank)
Part A.
1. Project Name Scotland Memorial Hospital - OR Expansion & Renovations
2. Location of land -disturbing activity: County Scotland City or Township Laurinburg
Highway/StreetLaunchwood Drive Latitude 34.7514 Longitude—79.4676
3. Approximate date land -disturbing activity will commence: 0 6 / 13 / 2 02 2
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3 . 4 7
6. Amount of fee enclosed: $ 100.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed NO
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jeff Thomas E-mail Address [e-mail]
Telephone [phone] Cell# 910-817-1960 Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Scotland Health Care System
[phone]
Name
Telephone Fax Number
500 Launchwood Drive
500 Launchwood Drive
Current Mailing Address
Current Street Address
Laurinburg, NC 28352
Laurinburg, NC 28352
City State Zip
City State Zip
10. Deed Book No. 1556 Page No.
9 0 — 92 Provide 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.
The Christman Company
[e-mail]
Name
E-mail Address
408 South E1m:Street
408 South Elm Street
Current Mailing Address
Current Street Address
Greensboro, NC 27406
Greensboro, NC 27406
City State Zip
City State Zip

Telephone [phone] Fax Number 336-273-4035
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.
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Title or Authority
Date
IOX LHM CL a Notary Public of the County of
State of North Carolina, herebycertify that ��� � �� y __ appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hid mdogptarial seal, this
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Page I of 3
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Doc I0: 002891910003 Type: GAP
Recorded: 08/11/2017 at 09.33.24 AM
Fee Amt: $22600 Page 1 of 3
i Revenue Tax: 200.00
Scotland County, NC
L Page Pratt III Register of Deeds
File# 2017-00002115
BK 1556 PG90-92
DEED
EDWARD H. JQHNSMN, JR
Prepared by: The Law Office of William R. Purcell II, PLLC
Post Office Box 1567
Laurinburg, North Carolina 28353
The Preparer is informed that the property conveyed does not include the primary residence of Grantor.
STATE OF NORTH CAROLINA
XT416,61 no
THIS DEED, made and entered into this the 3rd- day of August, 2017, by and
between SCOTLAND MEMORIAL HOSPITAL, INC., a North Carolina not for profit
corporation of 500 Lauchwood Drive, Laurinburg, North Carolina 28351 party of the first
part; to SCOTLAND COUNTY, apolitical subdivision of the State of North Carolina,
of 507 West Covington Street, parties of the second part;
WITNESSETH:
That the said party of the first part, for and in consideration of the sum of TEN
($10.00) DOLLARS and other good and valuable consideration to it paid, the receipt of
which is hereby acknowledged, has bargained and sold, and by these presents, does
bargain, sell, and convey unto the said party of the second part, its successors and

Page 2 of 3
assigns, are certain lots or parcels of land lying and being in Stewartsville Township,
Scotland County, North Carolina, and being more particularly described as follows:
Being all of those certain tracts or parcels of land located in the City of
Laurinburg, Stewartsville Township, Scotland County, North Carolina consisting of
two (2) tracts occupying a full block which is bounded on the north by McLean
Street on the west by King Street on the south by Covington Street and on the east
by Peden Street; also being all of that property as shown, described and depicted on
a topographical survey captioned "Preliminary not for construction 3.27 acre
topographic survey for Scotland Memorial Hospital, Inc." prepared by J.F.
Wampler Engineering, Inc. dated April 10, 2016, reference to said map being made
for a description of greater certainty.
It is the intent of the Grantor to grant to the Grantee all of it right title and
interest in and to property formerly known as the Edwin Morgan Center including
parking facilities and being all of the property lying within the block described
above.
Tract one (1) which consists principally of the parking lot was conveyed to
Scotland Memorial Hospital, Inc, by deed dated September 24, 2004, and recorded
November I I, 2004, in Book 945 at Page 54 of the Scotland County Registry.
Tract two (2) as well as Tract one (1) are a portion of those lands conveyed to
Scotland Memorial Hospital, Inc. by various Grantors between 1946 and 1948 for
the construction of Scotland Memorial Hospital said deeds being recorded in Deed
Book 2-0 at Page 289, Deed Book 2-B at Page 287, Deed Book 2-B at Page 289, Deed
Book 2-B at Page 288, Deed Book 2-B at Page 290, Deed Book 2-11 at Page 291, Deed
Book 2-D at Page 426, Deed Book 2-D at Page 427, Deed Book 2-1) at Page 428, Deed
Book 2-E at Pagc429, Deed Book 2-13 at Page 430, and Deed Book 2-D at Page 439.
TO HAVE AND TO HOLD the said lot or parcel of land and all privileges and
appurtenances thereunto belonging to them, the said party of the second part and its
successors and assigns in fee simple.
And the said party of the first part does covenant that it is seized of said premises
in fee and has the right to convey the same in fee simple; that the same is free from
encumbrances and that it will warrant and defend the said title to the same against the
claims of all persons whomsoever,

Page 3 of 3
IN TESTIMONY WHEREOF, the said panty of the first part has caused this deed
to be signed in its name by its President, all by authority duly given, all as of the day and
yeax first above written.
Scotland Me 'al Hospital, Inc
By: 0e.
Gregory ood, Its President
STATE OF NORTH CAROLINA
COUNTY OF SCOTLAND
I, r.' . a ! r10M , a Notary Public of the County and
State aforesaid, cer-tiCy that Grego C. Wood, either being personally known to me or
proven by satisfactory evidence, personally appeared before me this day and
acknowledged that he is President of Scotland Memorial Hospital, Inc., a North Carolina
corporation, and that he, as President, being authorized to do so, voluntarily executed the
foregoing on behalf of the corporation for the purposes stated therein.
y'IIf11f1/ii
••`'���-`CNN T�OTNESS my hand and official stamp or seal, thisday of August, 2017.
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