NCG550540_Owner (Name Change)_20221019

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR. NORTH CAROLINA
Director Environmental Quality
October 19, 2022
Richard D. Grimes
4648 Shelton Ridge Rd
Walkertown, NC 27051
Subject: General Permit NCG550000
Certificate of Coverage (CoC) NCG550540
4648 Shelton Ridge Rd
Forsyth County
Dear Permittee:
The Division has approved your request to transfer coverage under the subject General Permit.
Accordingly, the Division hereby issues you a revised version of NCG550540, along with a copy of
NCG550000. Discard any earlier versions of the permit and use this version until further notice. This CoC
is issued pursuant to the requirements of North Carolina General Statue 143-215.1 and the Memorandum of
Agreement between North Carolina and the US Environmental Protection agency dated October 15, 2007 [or
as subsequently amended].
PLEASE NOTE: Your facility discharges to a class B waterbody. Therefore, you will use the limits
and monitoring frequencies found in Part I, section C. (1.) of NCG550000.
If any parts, measurement frequencies or sampling requirements contained in this General Permit
are unacceptable to you, you have the right to request an individual permit by submitting an individual
permit application. Unless such demand is made, the certificate of coverage shall be final and binding.
This CoC is not transferable except after notice to the Division. The Division may require
modification or revocation and reissuance of the CoC. Contact the Winston-Salem Regional Office
prior to any sale or transfer of the permitted facility. Regional Office staff will assist you in
documenting the transfer of this CoC.
This permit does not affect the legal requirements to obtain any other State, Federal, or Local
governmental permit that may be required. If you have any questions concerning the requirements of the
General Permit, please contact Derek Denard of the NPDES staff [[e-mail]].
cc: NPDES file
Sincerely,
li V.7)7
.
for Richard E. Rogers, Jr.
Director, Division of Water Resources
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 11611 Mail Service Center I Raleigh, North Carolina 27699-1611
919.707.9000

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
S. DANIEL SMITH
Director
NORTH CAROLINA
Environmental Quality
NPDES Certificate of Coverage (CoC)
NCG550000 OWNERSHIP CHANGE FORM
TIM
I. Please enter the CoC number for which the change is requested.
Certificate of Coverage
N
C
G
5
5
II. Please provide the following for the requested change (revised CoC).
a. Request for change is a result of: MI Change in ownership of the residence/property
Name change of the facility or owner
If other please explain:
b. CoC will be issued to (person's name
or company name, if applicable):
c. Owner: person legally responsible for CoC: IC ATzh 62f ei M£ S
d. Facility name (if applicable):
e. Facility address:
f. Facility contact person:
First
MI Last
'4 B' SuccTitle 4 .7a1.3'65 s
Permit Holder Mailing Address
WA- t,►r.CZTOw!A. 144 G Z 705]
City State Zip
(% ) ,11-(OZ2- WeSlcioNit✓ 41 ►11/41te C ,0
Phone E-mail Address
Address
City
State Zip
[if different from Owner] first MI Last
i )
Phone E-mail Address
III. Contact person (if different from the person legally responsible for the CoC)
First
MI Last
Title
Mailing Address
City State Zip
1
Phone E-mail Address
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 11617 Mail Service Center I Raleigh, North Carolina 27699-1617
919.707.9000

NCG550000 OWNERSHIP CHANGE FORM
Page 2 of 2
IV.
V
Will this permitted facility continue to discharge the same volume and type of wastewater as
prior to this ownership or name change?
M Yes
No (please explain)
Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both facility -name change and/or facility ownership
change requests.
Legal documentation of the transfer of ownership (such as a property deed, relevant pages of a
contract, or a bill of sale) is ren wired for an ownership change request.
The certifications below must be completed and signed by the new applicant in the case of an ownership
change request.
CANT CERTIFICATION
attest that this application for a name/ownership change has been reviewed and is accurate and
ete to the best of my knowledge. I understand that if all required parts of this application are not
completed and that if all re a i d supporting information is not included, this application package will be
s com lete.
Zazz
ignature Date
PLEASE SEND IHE COMPLETE APPLICATION PACKAGE TO:
Mr. Charles H. Weaver
NC DEQ / DWR / NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
charles.weavergncdenr. gov

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
GENERAL PERMIT NCG550000
CERTIFICATE OF COVERAGE NCG550540
DISCHARGE OF DOMESTIC WASTEWATER FROM SINGLE FAMILY RESIDENCES AND
OTHER 100% DOMESTIC DISCHARGES WITH SIMILAR CHARACTERISTICS UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful standards and
regulations promulgated and adopted by the North Carolina Environmental Management Commission, and
the Federal Water Pollution Control Act, as amended,
Richard D. Grimes
is hereby authorized to discharge <1000 gallons per day of domestic wastewater from a
facility located at
4648 Shelton Ridge Rd
Walkertown
Forsyth County
to receiving waters designated as Mill Creek, currently a class B stream in subbasin 03-02-01 of
the Roanoke River Basin in accordance with the effluent limitations, monitoring requirements,
and other conditions set forth in Parts I, II, and III hereof.
This certificate of coverage takes effect 10/19/2022.
This Certificate of Coverage shall remain valid for the duration of the General Permit.
Signed this day 10/19/2022
ii 144
for Richard E. Rogers, Jr.
Director, Division of Water Resources
By Authority of the Environmental Management Commission

Book 3723 Page 1026
2022047023 00155
FORSYTH COUNTY NC FEE $26.00
STATE OF NC REAL ESTATE EXTX
$860.00
PRESENTED & RECORDED
10/14/2022 02:28:16 PM
LYNNE JOHNSON
REGISTER OF DEEDS
BY: CARLA B FLEMING, DPTY
BK: RE 3723
PG: 1026 -1028
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: $860.00
Tax Parcel Identification Number: 6858-08-9883.000
This instrument was prepared by: Philip E. Searcy, a licensed North Carolina attorney. Delinquent taxes,
if any, shall be paid by the closing attorney to the county tax collector upon disbursement of closing
proceeds.
Return to: Craige Jenkins Liipfert & Walker LLP, 110 Oakwood Dr., Suite 300, Winston-Salem, NC 27103
Mail Tax Bill to 4648 Shelton Ridge Road, Walkertown, NC 27051
Property Address: 4648 Shelton Ridge Road, Walkertown, NC 27051
Brief description for the Index: Lot 13, Shelton Ridge
THIS DEED made this I a
day of a 2022 by and between
GRANTOR
GARY F. ALLRED and wife,
DREAMA M. ALLRED
739 S. NC Highway 801
Advance, NC 27006
GRANTEE
RICHARD D. GRIMES and wife,
SHERLEEN B. GRIMES
4648 Shelton Ridge Road
Walkertown, NC 27051
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 the County of FORSYTH, State of North Carolina and
more particularly described as follows:
FOR PROPERTY DESCRIPTION, SEE EXHIBIT "A" attached hereto and incorporated
herein by reference.
submitted electronically by "craige Jenkins Liipfert & walker LLP"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Forsyth County Register of Deeds.

Book 3723 Page 1027
For back title reference, see the deed recorded in Book 2964 Page 3257 Forsyth County Registry.
THIS IS , OR IS NOT THE GRANTOR'S PRIMARY RESIDENCE
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, other than the
following exceptions: subject to easements and restrictions of record, if any; and 2022 property taxes.
IN WITNESS WHEREOF, the Grantor has duly executed the foregoing as of the day and year first above
written.
r
GARY F. ALLRED
STATE OF QC, L-- A.
COUNTY OF r
(SEAL) , r (SEAL)
DREAMA M. ALLRED
I, Y 1 f , a Notary Public for the County of O and State of
rl, do hereby certify that Gary F. Allred and vvrfe. Dreama M. Allr d either being personally
known to me or proven by satisfactory evidence (said evidence being NC, ), personally
appeared before me this day, and acknowledged the voluntary due execution of the foregoing instrument by
them for the purposes therein stated.
Witness my hand and Notarial stamp or seal this t tilt\day of ` N' , 2022.
1
Notary P .bliq
Name:
My Commission Expires:

Book 3723 Page 1028
EXHIBIT A
BEING KNOWN AND DESIGNATED as Lot Number 13, as shown on the Map of SHELTON RIDGE, as
recorded in Plat Book 32 at Page 55 in the Office of the Register of Deeds of Forsyth County, North Carolina,
reference to which is hereby made for a more particular description.
LESS AND EXCEPT that certain tract of land containing 0.87 acres, more or less, as shown recorded in Deed
Book 3063, Page 4045, in the Office of the Register of Deeds of Forsyth County, North Carolina, reference to
which is hereby made for a more particular description.
SUBJECT TO the Restrictive Covenants as recorded in Book 1623, Page 4286, in the Office of the Register of
Deeds of Forsyth County, North Carolina.