NCC230564_FRO Submitted_20230310

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 N/A in the blank.)
Part A.
1. Project Name
2. Location of land -disturbing activity: County wf City or Township a" l o�.�- A
Highway/Street US 1-- wq S2. Latltude(decimal degrees) Long itude(decimal degrees)
Approximate date land -disturbing activity will commence: 73-A"J , Zo 23
4. Purpose of development (residential, commercial, industrial, institutional, etc.): (o„. Me'rc.jA 1
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3. NA,
'7
6. Amount of fee enclosed: $ o® ^ 00 . 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 ❑ Enclosed X No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name /.r% A0el Ore; E-mail Address llf f_. FMlckael (!_� Ycthsa. Gowen
Phone: Office # /✓�%� Mobile # 33%' 3lo 2 - 5& W
9. Landowner(s) of Record (attach accompanied page to list additional owners):
r
t4..1J-C- 50-1108- 2zgl 3310-36Z-55&k(v
Name Phone: Office # Mobile #
yo3o Wake 6.ak Rd 5Tf 3qc' 4636 wakr Eames 2 :5T;� 3,01
Current Mailing Address �Current Street Address
galei�h /IC -Moct I�IC o�7(pCf'7
City State Zip City State Zip
10. Deed Book No. I r7qz Page No.I OP 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 name(s) of the owner(s) may be listed as the financially responsible party(les).
&anik y �s. U,G Gffk- InII - � o6 Ya4Co. Coves
Company Name —' E-mail Address
VOY6 14letke Fc s� f�'ol. 51'3qq �lb3o Wake {�+ 6d. 5TG- 3Hq
Current Mailing Address Current Street Address
� / C �11a0� �«Ieial� tNc o2't(oo�
City State Zip City State Zip
Phone: Office # ��9- �%f0 �9 Mobile # 3✓�l� ` Y(DZ_ 5loV6
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 for the 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:
wFSP ;s-lwd /4+ Gl />7ictice6ftahoo, cower
ame of Registered Agent E-mail Address
y�3a wr 6 &es� 9el, 5T 5! Y036 Wake Fors+ gd. 5T5- 3`(°t
Current Mailing Address ICurrent Street Address
A ctfei-Q NC_ ofto :R.W%6 0 C_ 21( n
City State Zip City State Zip
Phone: Office # 509— Wag- 22 K 9 - Mobile # A14
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 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)

(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 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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
_l1/%c�iae/ av 10-k T� �m�w✓ �f�%Q12 erg
Type or print nanie Title or Authority
U�ailidrj. '. / // r10,
// - 3- ZoZZ
Date
-------------------------------------------------------------------------------------------------------------------------------------
, a Notary Public of the County of S ucl
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 3&_day of _&OeM6I- , 20_2a
,t•(14 HAP, Nota
`..� �Q OgAfto r My commission expires � el boa 7
or w
• 'RJ6� 2?
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Continued from Items 9 & 90 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name
Phone:
Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City
State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone:
Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City
State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
op
Name
Phone:
Office # Mobile AN,
Current Mailing Address
Current Street Address
f
City State
Zip
City
State, t : Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 9 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #

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q8tf§ejcor8�9oum _)12112' n06?7AM a1 Document
3urry County, North Carolina Tax: $260.00
N. Todd Harris, Register of Deeds
Received By: MISTI COLLINS
Surry Co. Tax Dept.
Land Records SF
Collection SF
Revenue Stamp: $260.00
Prepared by and I
Return E-Record to: Hugh B. Campbell, III, Esquire, Campbell Law Group, PLLC
Parcel Identification No(s).: 5011-08-98-8452
NORTH CAROLINA
THIS DEED is made this 13'h day of December, 2021, by and between LONA SUE
MCCREARY, unmarried, Grantor, and GRANITE CITY INVESTMENTS, LLC, a North
Carolina limited liability company, Grantee, whose address is 1632 N Andy Griffith Parkway,
Mount Airy, NC 27030 whose mailing address is 196 Herring Street, Mount Airy, NC 27030.
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, sell and convey unto the Grantee in fee
simple, all that certain lot or parcel of land situated in the City of Mount Airy, MOUNT AIRY
Township, Sun-y County, North Carolina, and more particularly described as follows:
BEGINNING at a driven iron pin in the eastern right of way line of U. S.
Highway 52 at corner common to Carl E. Bell, et al, said beginning point being
located North 19 degrees 13 minutes 34 seconds East 1 foot from a granite
monument, and runs thence with line common to Carl E. Bell, et al, North 19
degrees 13 minutes 34 seconds East 298.94 feetile n set 5/8-inch rebar at corner
common to Bobby L. Martin; thence rAfla Pine common to Bobby L. Martin
South 40 degrees 57 minutes 03 seconds Ezst 777.R7 Tee,,l to a set 5/8-inch rebar
at corner common to Eva Caldwell and Wilfirnm Lovflfl; thience with line
common to William Lovill South 38 degrees 08 minutes �7 seconds West 101.51
Page 1 of 2
submitted electronically by "Campbell Law Group, PLLC"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the curry county Register of Deeds.

JK'l tV'Z t-lu -iu?jf UUU* 13VU000
Unofficial Document Unofficial Document
feet to an existing iron pin at corner common to William Lovill and Mrs. Bailey
Creed; thence with line common to Mrs. Bailey Creed and H. H. Smithers South
38 degrees 08 minutes 17 seconds West 171.09 feet to a set axle in the eastern
right off way line of U. S. Highway 52; thence with the eastern right of way line
of U. S. Highway 52 North 40 degrees 15 minutes West 680.15 feet to a driven
iron pin, the point of BEGINNING, containing 4.398 acres, more or less, as
appears from survey dated September 26,1987, byJoe L. Cooke, RLS # L-2970.
Property Address: 1632 N Andy Griffith Parkway, Mount Airy, NC 27030
The Property hereinabove described was acquired by Grantor by instrument recorded in Book
449, Pagel A2.7
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.
The Grantor covenants with the Grantee that Grantor is seized of the premises in fee simple
and 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 any exceptions herein stated.
IN WITNESS WHEREOF, the Grantor has hereunto set his hand and seal, or if corporate,
has caused this instrument to be signed in its corporate name by its duly authorized officers and its
seal to be hereunto affixed by authority of its Board of Directors, the day and year first above written.
(SEAL)
LONA SUE MCCREARY
To fkciHtote tche necaTalue of real property for taxation, N.C.G.S..§105-317.2 now
requires fir he GimintroT to oftite vAlaether the property includes the primary residence of the
Grantor. '-TLPmfs is go cerrfl!' 7 th mt the property described above does or XXX does not
contain my prrimnrny EreoideTmce.
1, Hugh B. Campbell, 111, a Notary Public for said County and State, do hereby certify that
LONA SUE MCCREARY did personally appear before me and acknowledge the execution of the
foregoing instrument. Witness my hand and notarial seal, this the 13' da of%DW ber-,2021.
My Commission Expires:
02-23-2022
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