NCG550916_Owner (Name Change)_20231026

ROY COOPER
Governor
ELIZABETH S. BISER
Secs erory
RICHARD E. ROGERS, JR.
DUrcrnr
NORTH CAROLINA
Environmental Quality
NPDES Certificate of Coverage (CoC)
NCG550000 OWNERSHIP CHANGE FORM
1. Please enter the CDC number for which the change is requested.
RECEIVED
OCT 26 2323
NCDEQ/DWR/NPDES
Certificate of Coverage
N I C I GI 515 U
H. Please provide the following for the requested change (revised CoC).
a. Request for change is a result of: 9 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:
L O V I j
First MI Last
l-lorrpe DLu-n
Title
31 (-)4- vex -Male ?�►'� ��.
Permit Holder Mailing Address
Ker✓ne-rsV7Ile pjc z-�Z`�+
City State Zip
(�336) 3919- ZZ5& Lkow/eq aar
Phone E-mail Address
d. Facility name (if applicable):
e. Facility address:
Address
City
State Zip
f. Facility contact person:
[if different from Owner]
First
MI Last
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
Phone E-mail Address
North Carolina Depattntent of Environmental Quality I Division of Water Resources
512 North Salisbury Street 1 1617 Mail Service Center I Raleigh, North Carolina 27699-lbl7
' - ---.-- V 919.707.9000
Oepvlmrt NON 01 r,WpNpgMN 11YLMY

Page 2 of 2
IV.
Will this permitted facility continue to discharge the same volume and type of wastewater as
pilor to this ownership or name change?
Yes
❑ No (please explain)
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
[v7� 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 roe deed, relevant pages of a
contract, or a bill of sale) is required for an ownership c ange request.
..................................................................................................................
The certifications below must be completed and signed by the new applicant in the case of an ownership
change request.
AP_� ANT CERTIFICATION
I, attest that this application for a name/ownership change 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 and that if all required supporting information is not included, this application package will be
returned as incomplete.
to 9 IX6Z3
Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Mr. Charles H. Weaver
NC DEQ / DWR / NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
[e-mail]

Book 3731 Page 1622
Drafted By: Bryan C. Thompson, Esq.
Freedman Thompson Witt Ceberio & Byrd, PLLC
This instrument prepared by Bryan C. Thompson, a
licensed North Carolina attorney, delinquent taxes, if
any, to be paid by the closing attorney to the County tax
collector upon disbursement of closing proceeds.
No Title Search Requested or Performed by
Drafting Attorney
2022053739 00136
FORSYTH COUNTY NC FEE $26.00
NO TAXABLE CONSIDERATION
PRESENTED & RECORDED
12/05/2022 03:43:55 PM
LYNNEJOHNSON
REGISTER OF DEEDS
BY: OLIVIA DOYLE, ASST
BK: RE 3731
PG: 1622 -1625
RECORDING TIME
NO EXCISE TAX PROBATE AND FILING FEE $ PAID
TRACT 1: PIN #: 6888-11-6605
Property Address: 3100 Drcxdale Drive, Kcrnersville, NC 27284.
TRACT II: PJN#: 6888-I1-8533
Property Address: 3104 T)rexdnle Drive, Kernersville. NC 27284.
Mail future tax bills to: Grantee at 7701 Vance Road, Kernersville NC 27284.
NORTH CAROLINA LIMITED WARRANTY DEED
THIS DEED made this . 5th day of -Dere-r%i er , 2022 by and between
GRANTOR
Theodore B. Johnson, Executor of the Estate of
Pearl V. Johnson, Deceased
7765 Baux Mountain Road
Germanton NC 27019
GRANTEE
Lori Johnson Rowley, married
7701 Vance Road,
Kernersville NC 27284.
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.
WITNESSE•TH
WHEREAS, Pearl V. Johnson died testate a resident of Forsyth County, North Carolina on January 6, 2022 (See
Forsyth County Estate File No.: 22-E-425); and
WHF.RF,AS, the Last Will & Testament of Pearl V. Johnson has been duly probated in the office of the Clerk of
Superior Court of Forsyth County, North Carolina; and
WHEREAS, the Lnst Will & Testament of Pearl V. Johnson provides a specific distribution to Grantcc; and
NOW. THEREFORE, the Grantor, under the specific power and direction contained in Article 11 Section 2.03 of
the Will of Pearl V. Johnson, and in consideration of mutual covenants other valuable consideration ($10.00 and o.v.c.)
has and by these presents does grant and convey unto the Grantee in fee simple, all that certain lot or parcel of land in
Forsyth County, North Carolina, more particularly described as follows:
See Exhibit A attached hereto and incorporated herein by reference.
Together with and subject to all casements and restrictions of record, if any.
submitted electronically by "Freedman Thompson Witt Ceberio & Byrd, PLLC"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Forsyth County Register of Deeds.

Book 3731 Page 1623
All or a portion of the property herein conveyed X_ includes or does not include the primary
residence of the Grantor.
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 save and except all easements and restrictions of record, if any,
and subject to any out conveyances of record prior to the date hereof by Pearl V. Johnson.
And the Grantor, as Executor of the Estate of Pearl V. Johnson does hereby covenant that he has not
placed nor suffered to be placed any presently existing liens or encumbrances against said premises, and that he
will warrant and defend the title to the same against the lawful claims of all persons claiming by, through, under
or on account of the Grantor, as Executor, insofar as it is his duty to do so by virtue of his office as Executor of
the Estate of Pearl V. Johnson, but no further.
IN WITNESS WHEREOF the Grantor has set her hand and seal the day and year first above written.
V, �24--, (seal)
Theodore B. Johnson, Executor of the Estate of
Pearl V. Johnson, Deceased
STATE OF NORTH CAROLINA )
COUNTY OF FORSYTH }
I, l: tt gill 11i �� ji, 'mlf , a Notary Public of Hy�-h i County, North Carolina, certify
that Theodore B. Johnson, Executor of the Estate of Pearl V. Johnson, personally appeared before me this day
and acknowledged to me that he voluntarily signed the foregoing document for the purpose stated therein and in
the capacity indicated.
WITNESS my hand and notarial seal, this 't' day of 2022.
EMILY A. SELLS-SALIE
Notary Public - North Carolina .
Forsyth County l rrd ' A
- y)il b.Li
- ��
cm ^�s { E•� °��'3► w Emil I A- c-e ils-sali e , Notary Public
(SEAL) My Commission Expires:

Book 3731 Page 1624
Tract I
BEGINNING at an iron stake at the sweet gum, former corner of D. M. Vance; thence with
Vance's line South 87' West 96 poles to a stake in the center of the creek in D. M. Vance's line;
thence with the center of said creek South 62° East 94 poles to a stake in center of said creek in
the Annie E. Crouse line, corner of D. W. Vance; thence along Vance's line North 14' East 48
poles to the point of BEGINNING containing 13.88 acres, more or less, SAVE AND EXCEPT
the following four tracts conveyed (1) .28 acres to James W. Holden by deed recorded in Deed
Book 796, Page 83; (2).57 acres to James W. Holden by deed recorded in Book 1381, Page 70;
(3) .09 acres to William R. Vaughn by deed recorded in Deed Book 990, Page 141; (4) .68 acres
to Jack S. Holden by deed recorded in Book 1381, Page 269.

Book 3731 Page 1625
Tract II
BEGINNING at a new iron pipe within the property of James M.
Johnson as described in Deed Book 1677 at page 1160, Forsyth County
Registry, said point of BEGINNING being two course and distances
from an established iron stake at the southwest corner of the
property of Edgar C. Brooker as described in Deed Book 1622 at page
3520, Forsyth County Registry as follows: (1) South 86049110" East
41.53 feet to a point; (2) thence south 03010150" West 30 feet to
the point of BEGINNING, thence South 03010150" West 150 feet to a
new iron pipe; thence South 55027131" West 215.75 feet to a new
iron pipe; thence South 55027'31" West 10 feet to a point in the
center of Dean Crank in the north line of the property of David
Hubert MUstiRegis y; thencebed wi hn Deed Book 1582 at the centerline of said creek e 1029, andstthhe
County Registry;
north line of the property of Mustin, four courses and distances as
follows: (1) North 27058127" West 26.35 feet to a point; (2) thence
North 62053131" West 54.32 feet to a point; (3)
South
85,05158" West 14.87 feet to a point; (4) thence North 84056'50"
West 43.37 feet to a point; thence leaving the center line of said
creek, North 34043138" East i0 feet to a new iron pipe; thence
continuing North 34043'38" East 276.56 feet to a new iron pipe;
iron atSouth 75.748feet,to11thest a point�and placetal of of g et passing over a new
ofBEGINNING, containing
1.181 acres, more or less, and being a part of Tax Lot 11G, Block
being Re Township an
sin County Tax Maps,
and
being a part ofthatproperty describedDed Book 1677tpage
1160, Forsyth County Registry according to a survey made by Larry
L. Callahan, M. Johnson and wife, Pearl March Vdated ohnson,"9being iJob dNo. a7p for James
209-3
TOGETHER with an easement thirty (30) feet in width for purposes of
ingress, egress and regress from and to the above described
property to and from the southern terminus of Drexdale Drive, being
also designated as State Road 2075, with easement shall be
appurtenant to and run with the above described land and being more
particularly described as follows:
BEGINNING at a point in the southern terminus of Drexdale
Drive, said point being North 86053159" West 7.62 feet from the
southeast terminus of Drexdale Drive; said BEGINNING point being
forth
set
the orthwest Deed Bookcorner
i622of tat pa - Brooker
gee3520,f Forsyth County Registry;
thence with the west line of Brooker, South os°09131" West a total
distance of 199.75 feet to an established iron pipe and passing
over a new iron pipe at 30.11 feet; thence with the south line of
Brooker property, South 86049010" East 41.53 feet to a point;
thence south 03020250" Vast 30 fast to a new iron pipe at the
northeastern most corner of the 1.18i acre tract above described;
thence with the north line of said 1.181 acre tract, North
86049110" West 74.26 feet to a new iron pipe; thence North
09909131" East 230 feet to a point in the south terminus of
Drexdale Drive; thence along the south terminus of Drexdale Drive,
South 86053159' East 30 feet to the point and place of BEGINNING.
'0