NCC223752_FRO Submitted_20221107

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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name r �•
2. Location of land -disturbing activity: County f � n r • , City or Township
Highway/Street Al Cn1Oyv1 Latitude(dearreldegrees)� Long itude(ded.i&a,e.$)"4D NS"I
3. Approximate date land -disturbing activity will commence: 1j • I ' Z Z
4. Purpose of development (residential, commercial, industrial, institutional, etc.): 66 rA�'V CyGic�
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3 �°
6. Amount of fee enclosed: $ . 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 ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name ��A \�AUQ�.vt
E-mail Address LIA�t'�oS3CoriYQtF�N�,lra+v�
Phone: Office # N 1 a
Mobile # r
DG 3
W^
9. Landowner(s) of Record (attach accompanied page to list additional owners):
f kJ le" flYo 7L4 q z sq
Name ( Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No_ -JI O 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 namefs) of the owner(s) maybe listed as the financially responsible party(ies).
Company Name
Ef ,
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
_� 0 c) of vJ Sa`P.vtn fm
Current Street Address
0 o" 1, C `-1( Lyg)
City State Zip
Mobile # i. C .
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 forlhe 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
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
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:
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State Zip
Mobile #
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.
Company 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 attomey-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 informafion provided herein.
Type o print name
Title or Authority
Z,z2
Date
I. ; ��� � , �) eo" , a Notary Public of the County of
i
State of North Carolina, hereby certify tha appeared personally
before me this day and being duly sworn acknowl dged that he abo a fo was executed by himfher.
Witness my hand and notarial seal, this day of LnI2
d�DU A . %(ryh��
gp,Y T
�QiAR4 Notary
G AU13 L%G G, My commission expires IILLk(d�16.2y

BK 7764 PG 0790
k.�'.0 [ s. 5 DEED OF GIFT
FILED
UNION COUNTY, NC
CRYSTAL D. GILLIARD
REGISTER OF DEEDS
FILED Aug 07, 2020
AT 02:06 pm
BOOK 07764
START PAGE 0790
END PAGE 0793
INSTRUMENT # 30118
EXCISE TAX (None)
cG
NO TITLE EXAMINATION REQUESTED OR PERFORMED
Tax Lot No: Parcel Identifier No. 08-051-005E
Verified by County on the day of , 2020 by
Mail after recording to Hehns Robison Lee & Bennett, P.A.
"This instrument was prepared by R. Kenneth Helms, Jr. ror
Brief Description for the index 9.989 acres, Goose Creek Township
NORTH CAROLINA GENERAL WARRANTY DEED
made August 5, 2020 by and
GRANTOR
JOEL J. BARHAM and SHERRI P. BARHAM,
Trustees of THE BARHAM FAMILY TRUST,
dated July 18, 2008
1514 Sikes Mill Road
Monroe, NC Z8110
GRANTEE
PROVISION CHURCH OF UNION COUNTY, INC.
4114 Salem Pointe Drive
Monroe, NC 28110
Fnicr in apprupnaic block for e3ch parry name, address, and, ifappropriate, characler of cmity, e.g., corporation or partnership.
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 Goose Creek Township, Union County, North Carolina
follows. and more particularly described as
B[ING ALL of that certain tract of land designated as Tract #2 on survey by Carolina Surveyors, Inc., dated
December 12, 2019, containing 9.989 acres, said survey being recorded in Plat Cabinet P, File 19 in the Office of the
Union County Register of Deeds.
All or a portion of the property herein conveyed _ includes or X does not inclucic the primary residence of a
Grantor.

BK 7764 PG 0791
The property hereinabove described was acquired by Grantor by instrument recorded in Book 7182, Page 683, Union County
Registry.
A map showing the above described property is recorded in Plat Cabinet P, File 19.
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 rtuAdable 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:
APPLICABLE ZONING; ANY EASEMENTS AND RIGHT'S OF WAY FOR SERVICE LINES, ROADS AND
UTILITIES AS MAY BORDER OR CROSS THE PROPERTY INCLUDING, IF APPLICABLE, THE SUBDIVISION
STREETS AS SHOWN ON RECORDED PLAT; ANY EASEMENTS RESERVED IN THE RESTRICTIVE
COVENANTS, INCLUDING HOMEOWNERS ASSOCIATION PROVISIONS; APPLICABLE RESTRICTIVE
COVENANTS OF RECORD AND STREET ASSESSMENTS; 2020 REAL PROPERTY TAXES; SUBJECT TO
MATTERS THAT COULD BE REVEALED BY A CURRENT ACCURATE PHYSICAL AND BOUNDARY SURVEY
AND ACTUAL INSPECTION OF THE PROPERTY.
IN WTTNESS WHEREOF, the Grantor has duly executed the foregoing as of the day and year first above written.
THE BARHAM FAMILY TRUST,
dated July 18, 2008
��h/� ��N✓1�t~ (SEAL)
el J�m,/Trustee
>
c V (SEAL)
Sherri P. Barham, Trustee
NORTH CAROLINA, UNION COUNTY.
I, the undersigned a Notary Public of the County and State aforesaid, certify that JOEL J.
SEAL- BARHAM and SHERRI P. BARHAM as Trustees of The Barham Family Trust dated
STAMP July. 19, 2008, Grantor, personally appeared before me this day, each acknowledging to me
15,,,1VIIIIIFI!(,,��/+ that he or she voluntarily signet) the foregoing instrument for the purpose stated therein and in
O, RO the capacity indicated.
�c
NOT"4Ry This day of August, 2020.
PUBLIC .
Notary Public
(Typal or printed name of Notary)
My commission expires: 1 - ` t Al.

BK 7764 PG 0792
EXHIBIT'
CERTIFICATE OF TRUST
The undersigned Trustees hereby certify the following:
This Certificate of Trust relates to the trust created by that certain The Barham Family
Trust dated July 18, 2008 ("Trust").
2. The name of the Grantor is The Barham Family Trust dated July 18, 2008.
3 The name of the Trustees are Joel J. Barham and Sherri P. Barham.
4. The name and address of each trustee empowered to act under the Trust Agreement at the
time of the execution of this Certificate of Trust is:
TRUSTEES
Joel J. Barham
1514 Sikes Mill Road
Monroe, NC 28110
Sherri P. Barham
1514 Sikes Mill Road
Monroe, NC 28110
The trustee is authorized by the Trust Agreement to sell, convey, pledge, mortgage, lease,
manage, operate, control, transfer title, divide, convert or allot the trust property,
including real and personal property including but not limited to securities of all kinds,
and to sell upon deferred payments, except as limited by the following (if none, so
indicate): NONE
The Trust owns the real estate located in Union County, State of North Carolina more
particularly described in this Deed.
The undersigned hereby represents that the statements contained in this Certificate of
Trust are true and correct, and that there arc no other provisions in the Trust Agreement
or amendments to it that limit the powers of the Trustee to sell, convey, pledge,
mortgage, lease, manage, operate, control, transfer title, divide, convert, allot or sell upon
deferred payments trust property, including real and personal property, This trust has not
been revoked, modified, or amended in any manner which would cause the
representations in this certification of trust to be incorrect. This trust is being signed by
all currently acting trustees of the trust.
(SIGNATURE PACE FOLLOWS1

BK 7764 PG 0793
THE BARHAM FAMILY TRUST
DATED JULY 18, 2008
Bye i-m A- — (SEAL)
oe1 I. ham, Trustee /
By:
�` �"
hem Trustee
STATE OF NORTH CAROLINA
COUNTY OF UNION
1, the undersigned, a Notary Public of the County and State aforesaid, certify that JOEL J.
BARHAM and SHERRI P. BARHAM as Trustees of The Barham Family Trust dated
July 18, 2008, Grantor, personally appeared before me this day, acknowledging to me that he or she
voluntarily signed the foregoing instrument for the purpose stated therein and in the capacity
indicated.
This the U'44 day of August, 2020
ti tv C. �4� Notary Public
(rypai or Pnnred Namc of Notary)
`\``xl-' 1l111111lllflgl��l' "''i
Q,O�IN 0, R� 4
My commission expires: �' �'1P
140TAI r -
AUBLiC
?!O �O