NCG030672_Name-Owner Change Application_20230224

NC DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF Energy, Mineral, and Land Resources
STORMWATER PROGRAM
NORTH CAROLINA
Environmental Quality
NPDES STORMWATER PERMIT NAME/OWNERSHIP CHANGE FORM
CURRENT PERMIT INFORMATION:
Permit Number: NCS___/_/_/__/_/ or NCG►►� Si -7/ Z
1. Facility Name (prior to change):
II. NEW OWNER/NAME INFORMATION:
2..This request for a name change is a result of:
%
r a. Change in ownership of property/company
b. Name change only (Facility and/or Company)
c. Other (please explain):
(for example, facility address update. Include additional attachments if necessary.)
3. New owner's name (name to be put on permit as Permittee):
75oAkA fA(DriCA+1o1J UO1
4. New owner's or signing official's name and title: —XUS-iila c-Qfzoke-
(Person legally responsible for permit)
HUM" &EWCAS t S*&N MR�er
(Title)
5. Mailingaddress:215 Su16errA RA City: Si Coe,
State: Alc Zip Code: 217-01 Phone: (q10 ) IUJ3- ?i34$
E-mail address: 1
6. New facility name (if applicable): 7TC�d©Aa 40JGIR4C (Abr C*JSotJ U
7. Effective date of transfer or name change:
North Caro�find DepilrYment ofEnvfrOnmentjl Qu tlit
y "I DiviSfrut UfI;�lar�
sl tvafrh salishury Slre>ct / I6I21,faf1S'ervlc,e Confer l Rakigh, Nurfh
919,7079200

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
III. PERMIT AND FACILITY CONTACT INFORMATION
8. New permit contact's name and title: I` lC &iAt
(Permit Contact)
WC1+9 K&J,05tt-
(Title)
9. Mailing address: 21S Pb City: Biscrof,
State: Zip Code: 9-72oa Phone: (W )1420- 2349
E-mail address: ,imcforidQ��ord�tt
10. New facility contact's name and title: :Y )64(w `�G &14
(Facility Contact)
Sam M,W0_
(Title)
11. Mailing address: 2.7 ,1� Se&g rN (� City. &.SGO(,
State: A Zip Code: 2,72A Phone: (q 1 ©)
E-mail address: eftLktjALdAN - 64b • CA41
12. New billing contact's name: .4(w
(Billing Contact)
13. Mailing address: '176 Saberr4 ED City: 61,sco °L
State: Zip Code: 2.7 Phone: (qlO ) 42$-23b6
E-mail address: MLbdalt ► dA,0 4Afo •(iQM
IV. FACILITY ACTIVITIES AND DISCHARGE INFORMATION
1. Will ind stria) activities at the facility remain the same as under the previous owner?
Yes j No ❑
2. Will the stormwater discharge location(s) remain the same? Yes 2l""No ❑
NOTE: If either of these questions is answered "No," then more information is needed to review
the request. Please attach documentation to describe and explain the changes to the facility
activities, stormwater discharges, and/or outfal/ location. Depending on the information
provided, the Division may require that the new owner file a new permit application.
Last Revised 3/13/1011

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS
ALL OF THE ITEMS LISTED BELOW ARE INCLUDED.
REQUIRED ITEMS:
1. This completed application form (with original signature)
2. Legal documentation of transfer of ownership (such as relevant pages of a deed or a bill of sale) is
required for an ownership change request. Articles of incorporation are not sufficient for an
ownership change but can be provided for a name change.
3. Information to document facility, industrial activities, stormwater discharges, or outfall changes
as noted in item IV above (if appropriate)
Why is this information needed?
Regulations in 40 CFR §122.63 allow for minor modifications to NPDES permits for a change of
ownership or operational control of a facility, provided that information supports that no other change
in the permit are necessary.
Why does this form need to be mailed in?
Permittees and applicants must fulfill signatory requirements in the NPDES federal
regulations in 40 CFR §122.22 (please see those regulations for guidance). Until NCDEQ's
electronic submission process meets Cross -Media Electronic Reporting (CROMERR)
requirements, this original signed (not digital signature) form must be mailed to the
address below. The uploaded copy is stored as part of the permit record in the Division's
digital repository.
Applicant's Certification:
uscm t JellSfAattest that the application for a name and/or ownership
change submitted has been reviewed and is accurate and complete to the best of my
knowledge. I understand that if all required parts of this application are not completed, or if all
required supporting information is not included, this application package will be considered
incomplete and may be returned.
Signatur ._ ��L" Date: S-94-2421
THE CO LETED APPLICATION AND ALL SUPPORTING INFORMATION SHOULD BE SENT TO:
DEMLR Stormwater Program
512 North Salisbury Street, 61h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Last Revised 311312022

BOOK B]B PAGE 870(3) 369350
ItlII�IIIII�IIINII�'llllll
This document presented and filed:
07/23/2021 04:13:59 PM
Melissa F. Pipkin, Montgomery County, NC
REAL ESTATE EXCISE TAX: $10,745.00
Excise Tax: $10,745.00
Map No. 756814345226, 756805272860, 756805271923, 756805281105, 756814331850, 756814431931
Mail after recording to: Grantee
This instrument prepared by: Hollers & Atkinson, P.C., 110 N. Main St., Troy, NC 27371
Brief description for the Index: Tracts on Sedberry Rd. and Wright Rd., Town of Biscoe, Biscoe Township_
NORTH CAROLINA GENERAL WARRANTY DEED
THIS DEED made this 23rd day of July, 2021, by and between:
GRANTOR GRANTEE
Kellam Properties 1, LLC Jordan Innovative Fabrication, LLC
275 Sedberry Rd. 1939 NC Hwy 109 S
Biscoe, NC 27209 Mount Gilead, NC 27306
WITNESSETH, that the Grantor, for a valuable consideration paid by the Grantee in fee simple, the receipt of
which is hereby acknowledged, has and by these presents does grant, bargain, sell and convey unto Grantee in
fee simple, all of its right, title and interest in those certain lots or parcels of land situated in Biscoe Township,
Montgomery County, North Carolina and more particularly described as follows:
Tract 1: Being that tract or parcel of land containing approximately 15.00 acres as shown on
the map of the "Survey for: Kellam -McIntyre Machine Company, Inc." which is recorded in
Plat Cabinet E, Slide 31-B in the Montgomery County Registry, which survey map is
incorporated by reference.
Tract 2: Being all of Parcel C, containing approximately 1.82 acres, as shown on the map of
"A Division of the Montgomery Farms, LLC Property" recorded in Plat Cabinet G, Slide 80A
in the Montgomery County Registry, which survey map is incorporated by reference.
Tract 3: Being all of that parcel or tract of land containing approximately 1.95 acres as shown
on the survey map recorded in Plat Cabinet E, Slide 200-D and Plat Cabinet F, Slide 1-A in the
Montgomery County Registry, which survey map is incorporated herein by reference, LESS

AND EXCEPT that parcel containing approximately 0.43 acres previously conveyed by deed
recorded in Book 834, Page 313.
Tract 4: Being all of Parcel B, containing approximately 1.72 acres, as shown on the map of
"A Division of the Montgomery Farms, LLC Property" which is recorded in Plat Cabinet G.
Slide 80A in the Montgomery County Registry, which survey map is incorporated by reference.
Tract 5: BEGINNING at a point in the center line of NCSR 1556, the northwest corner of the
Town of Biscoe property, and running thence with the center line North 13-1.7-21 East 221.07
feet to a point; thence South 75-51-40 East 669.61 feet to a rebar; thence South 07-04-57 West
286.52 feet to a rebar; thence North 70-42-05 West 704.39 feet to the BEGINNING, containing
approximately 3.96 acres.
Tract 6: Being all of that tract or parcel containing approximately 14.22 acres as shown on the
map of the 'Boundary Survey for: Kellam Properties I, LLC" which is recorded in Plat Cabinet
F, Slide 4-C in the Montgomery County Registry, which survey map is incorporated by
reference.
Does this property include the Grantor's primary residence? Yes X No
This property was acquired by the Grantor by instruments recorded Book 669, Page 214; Book 834, Page 282,
Book 759, Page 33; Book 669, Page 209; and Book 670, Page 50.
Maps showing this property are recorded in Plat Cabinet E, Slide 31-13; Plat Cabinet G, Slide 80A; Plat Cabinet
E, Slide 200-1); Plat Cabinet F, Slide 1-A; and Plat Cabinet F, Slide 4-C.
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances hereto
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 except for the exceptions
hereinafter stated. Title to the property hereinabove described is subject to the following exceptions:
(a) the lien of ad valorem real property taxes and assessments that are not yet due and payable
for the current year; (b) all easements, restrictions, covenants and other matters of record; (c)
all matters that would be disclosed by a current, accurate survey of the Property; and (d) zoning,
land use and building laws, regulations and ordinances affecting the Property.
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 officer, the day and year first above written.

Ke- am P operties , . TIC.
(SEAL)
e ly . K llam, Manager
STATE OF NORTH CAROLINA )
COUNTY OF n{{)
I, .a y �A�So�S , a Notary Public of the State and County named above, do
certify that on this Rlyd _ day of , 2021, before me personally appeared Kelly S.
Kellam, and being duly sworn, says that is the Manager of Kellam Properties I, LLC, a North Carolina
limited liability company, and that by authority duly given and as the act of the company, he signed the
foregoing instrument in its name on its behalf as its act and deed.
�Nota�ryub�lic��
My commission expires: 3-1-dbaq
(SEAL)

BOOK 878 PAGE 865(3) 369347
III IIIIIIII�I���(llilllll�il Ill �II
This document presented and filed:
07/23/2021 04:11:27 PM
Melissa F. Pipkin, Montgomery County, NC
REAL ESTATE EXCISE TAX: $1,100.00
Excise Tax: $1,100.00
Map No. 7578 09 06 6111
Mail after recording to: Grantee
This instrument prepared by: Hollers & Atkinson, P.C., 110 N. Main St., Troy, NC 27371
Brief description for the Index: 509 Hunsucker St., Town of Biscoe, Biscoe Township
NORTH CAROLINA GENERAL WARRANTY DEED
THIS DEED made this 23rd day of July, 2021, by and between:
GRANTOR
Kellam -McIntyre Machine Co., Inc.
275 Sedberry Rd.
Biscoe, NC 27209
GRANTEE
3
rnA
I 'i ID (0 1 0" _� 0
Jordan Innovative Fabrication, LLC
1939 NC Hwy 109 S
Mount Gilead, NC 27306
WITNESSETH, that the Grantor, for a valuable consideration paid by the Grantee in fee simple, the receipt of
which is hereby acknowledged, has and by these presents does grant, bargain, sell and convey unto Grantee in
fee simple, all of its right, title and interest in those certain lots or parcels of land situated in Biscoe Township,
Montgomery County, North Carolina and more particularly described as follows:
Situate on the north side of Hunsucker Street, also NCSR 1500, and on the east side of
McCaskill Street approximately 400 feet south of the intersection of McCaskill Street with NC
Highway 24/27, and described as follows:
BEGINNING on an old iron pipe corner beside an old decayed pitch pine stump, the northwest
corner of the Cassie McCaskill tract and supposed to be the southwest corner of the J.R. Miller
tract, also the southeast corner of the Clem Dowd tract, and running thence with the old line of
the W.B. Hicks tract of which this is a part, also a line of Dowd, North 83-36 West 510.3 feet
to a hub in the east line of McCaskill Street; thence with the east line of McCaskill Street, South
18-26 West 373.8 feet to a stake in the intersection of McCaskill and Hunsucker Streets; thence
with the north line of Hunsucker Street/NCSR 1500, South 82-08 East 590.1 feet to a hub in
the north line of said street, and in the old line of the W.B. Hicks tract of which this is a part

and Cassie McCaskill; thence with the said old line North 06-04 East 3773 feet to the
BEGINNING, containing 204,574.6 square feet or 4.7 acres, more or less, according to a 1972
survey, a map of which is attached as an exhibit to the deed recorded in Book 166, Page 617..
Does this property include the Grantor's primary residence? Yes X No
The law firm of
has neither examined nor certified as to the title to the property.
This property was acquired by the Grantor by instrument recorded Book 166, Page 617.
A map showing this property is recorded in
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances hereto
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 except for the exceptions
hereinafter stated. Title to the property hereinabove described is subject to the following exceptions:
(a) the lien of ad valorem real property taxes and assessments that are not yet due and payable
for the current year; (b) all easements, restrictions, covenants and other matters of record; (c)
all matters that would be disclosed by a current, accurate survey of the Property; and (d) zoning,
land use and building laws, regulations and ordinances affecting the Property.
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 officer, the day and year first above written.
Kell - cIntyre Machine Co., Inc.
(SEAL)
Robert E. Kellam, President
(notary certificate on following page)

STATE OF NORTH CAROLINA )
COUNTY OF.
L - IASa L--.. o,( n . a Notary Public of the State and County named above, do
certify that on this Q3fA day of , 2021, before me personally appeared Robert E.
Kellam, and being duly sworn, says that is the President of Kellam -McIntyre Machine Co., Inc., a North
Carolina business corporation, and that by authority duly given and as the act of the corporation, he signed
the foregoing instr anent in its name on its behalf as its act and deed.
aw4'aj-- L,4t.r� My commission expires: 3,7
-ROA
Notary Public
(SEAL)
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