NCC231976_FRO Submitted_20230628

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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. II
1. Project Name (1& C r t (Y , ( 5�� ` CUcTlov
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County `5,x'61dA/1 City or Township VI 115 L
Highway/Street\U,O1A ,C Latitude(decimal degrees) 6•I4 Longitude(decimal degrees)a* P'✓7
3. Approximate date land-disturbing activity will commence: 1 l i I Z
4. Purpose of development(residential, commercial, industrial, institutional, etc.): VISIVA04
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): Z.
6. Amount of fee enclosed: $ ZOO ov . 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 ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
II ,
Name ®iob�( E-mail Address rat l; t (A,r s,()(n(j
Phone: Office# 336 r 6 Gc" If Z (f Mobile# 3J‘) ` ;14-7361
9. Landowner(s)of Record (attach accompanied page to list additional owners):
1-1/1 wig PRi �'LS 3 3C- 53 r—7775
Nam& Phone: Office# Mobile#
2259 SV►t( LAVA Zp I. C
Current Mailing Address Current Street Address
Wf nsSILI NC -Gott
City State Zip City State Zip
10. Deed Book No. .1 0-1Page No. 40 Provide a copy of the most current deed.

1
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(ies).
ISEAINAT LeAA-R-5 (LC kAilAt'-v\i„ e asev,iftot,r6ve•Cow
Company Name E-mail Add(ess
¶1I( Dr r
Current Maili Address Current Street Address
Vs C 27(03
City State Zip City State Zip
Phone: Office# 36"Gq ` Z lU Mobile# J (" 45® (Q 2
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:
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 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
P Y
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.
WIC;- C51iFr-044) PU51a„IC
T b or prim name Title or Authority
Z 2:�
ignature Date
I, I C_1"‘0 hd A m ChQ1 T,Q , a Notary Public of the County of Ft)f SL1Y)
State of North Carolina, herebycertifythat Whiff G -�-� 4 l
O'r appeared personally
before me this day and being duly sworn acknowledged tha the above form was executed by him/her.
Witness my hand and notarial seal, this IN I day of "Skk r 20 a 3
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2020001924 011
FORSYTH CO. NC FEE$26.00
NO TAXABLE CONSIDERATION
PRESENTED&RECORDED
01/15/2020 12:24:57 PM
LYNNE JOHNSON
REGISTER OF DEEDS
BY: EVELYN R. DIXON
DPTY
BK: RE 3503
PG: 460-462
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: No Taxable Consideration
Tax Parcel Identification Number: 5897-61-0942.00
This instrument was prepared by: T. Lawson Newton, 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.
NO TITLE SEARCH PERFORMED OR REQUESTED
Return to: Craige Jenkins Liipfert& Walker LLP, 110 Oakwood Dr., Suite 300, Winston-Salem,NC 27103
Mail Tax Bill to: 2255 Lewisville Clemmons Road, Suite C, Clemmons,NC 27012
Property Address: 2255 Lewisville Clemmons Road, Suite C, Clemmons,NC 27012
Brief description for the Index: See attached Exhibit"A"
THIS DEED made this -°\ day of Th nUQ,vy 2020 by and between
GRANTOR GRANTEE
CORVUS, LLC THYME PROPERTIES, LLC
A North Carolina Limited Liability Company A North Carolina Limited Liability Companpy
2255 Lewisville Clemmons Road, Suite C 2255 Lewisville Clemmons, Road, Suite C
Clemmons,NC 27012 Clemmons,NC 27012
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:
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.

FOR PROPERTY DESCRIPTION, SEE EXHIBIT "A" attached hereto and incorporated
herein by reference.
For back title reference, see the deed recorded in Book 3351 Page 3482 Forsyth County Registry.
THIS IS OR IS NOT i/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 2020 property taxes.
IN WITNESS WHEREOF, the Grantor has duly executed the foregoing as of the day and year first above
written.
CORVUS,LLC, a North Carolina Limited Liability Company
(SEAL)
Name: ft,/X'X�-/' -__i e i i/V/6-6 ?1iV 2i LC 2
Title: Member/Manager
STATE OF (\13P(1n 0c c\1fYA
COUNTY OF rox.s\1 k\
I, E\17 r's1(}4.�'�� _`=,<c' c , a Notary Public of the County of 1 .1;-11 and State of
CM \(\ , certify that N Z \c( G o,"1_'za\ 'Z , either being personally known to
me or proven by satisfactory evidence (said evidence being North Carolina Driver's License), who is the
Member/Manager of CORVUS, LLC, a North Carolina Limited Liability Company, personally appeared
before me this day and acknowledged that he/she is Member/Manager of CORVUS, LLC, a North Carolina
Limited Liability Company and that as Member/Manager being duly authorized to do so,voluntarily executed
the foregoing instrument on behalf of said company for the purposes stated therein.
WITNESS my hand and notarial seal,this (1 "day of )ar `l.ivs , 2020.
Notary Public rh ELIZABETH F.SEARCY
Name: Ell 7(.1 0Q,.� 1 �~ "';Q !'ti, Notary Public,Forsyth cot nf�r
My Commiss on Expires r I:4>, A
My Commission Expires: 1 1 1;?f�12 ;;;t),

EXHIBIT A
Deed Description for Deed from Corvus, LLC to Thyme Properties, LLC
BEGINNING at an iron rebar located at the intersection of the Northern line of Anne E. Sapp
(see Deed Book 3308, Page 1892, Forsyth Registry), the Southwesternmost corner of Melanie
Paschal and Jared D. Sizemore (see Deed Book 2918, Page 3645, Forsyth Registry) and the
Southeasternmost corner of the herein described tract; Running thence from said Beginning
point with the Northern line of Sapp as referenced above (and others) North 84° 30' 28" West
386.15 feet to a concrete monument with an existing iron rebar; thence North 87° 38' 25" West
24.28 feet to an existing iron pipe; thence North 88° 22' 28" West 41.74 feet to a 1/2 inch
existing iron pipe; thence North 88° 22' 28" West 19.99 feet to an existing iron pipe; thence
North 87° 59' 24" West 159.98 feet to an existing iron pipe; thence North 87° 59' 24" West
270.05 feet to a 1/2 inch existing iron pipe; thence North 88° 47' 10" West 325.06 feet to a 1/2
inch existing iron pipe; thence North 45° 09' 22" East 245.93 feet to an existing iron pipe;
thence North 53° 09' 00" East 179.70 feet to a 3/4 inch existing iron pipe; thence North 30° 35'
50" East 159.06 feet to a 3/4 inch existing iron pipe; thence North 33° 29' 26" East 127.87 feet
to a 3/4 inch existing iron pipe; thence North 52° 29' 59" East 303.20 feet to a Point; thence
North 37° 45' 20" East 277.56 feet to a 3/4 inch existing iron pipe; thence with the Northern
line of Crow Hill Homeowner's Association (see Deed Book 2928, Page 370, Forsyth Registry)
North 87° 11' 13" East 462.82 feet to a 3/4 inch existing iron pipe; thence with the Western line
of Gerald Edward Allen Douthit (Tax PIN 5897-61-6961.00 of the Forsyth County Tax Maps as
presently constituted) South 0° 33' 48" West 692.22 feet to an existing iron rebar; thence South
0° 23' 28" West 130.95 feet to an iron rebar; thence South 0° 49' 07" West 200.32 feet to an
existing iron rebar, the point and place of beginning.
This tract contains 19.749+/- acres and is designated as Tax PIN 5897-61-0942.00 of the Forsyth
County Tax Maps as presently constituted. This description is taken from a survey prepared by
John Edward Beeson Professional Land Surveyor dated December 20, 2019 entitled "Boundary
Survey for Corvus, LLC."