NCC233444_FRO Submitted_20231121

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 NCGO1 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.
1. Project Name_NOrthchase Library
'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).
n/a
2. Location of land-disturbing activity: County New Hanover City or Township._Wilmington
Northchase Parkway 34.312719 LOn degrees)
77 878978
Itude decimal Highway/Street Latitude(decimal degrees) g c
3. Approximate date land-disturbing activity will commence: 1/2/24
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_lnstitutional
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.42 ac.
6. Amount of fee enclosed: $300.00 • . 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 I] No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Kevin E. Cais mail Address [e-mail]
Name 910-264-6720
-Phone:Office#-910-798=4338 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
New Hanover County 910-798-4338 910-264-6720
Name Phone: Office# Mobile#
200 Division Dr. _ 200 Division Dr
Current Mailing Address Current Street Address
Wilmington, NC 28401 Wilmington, NC 28401
City State Zip City State Zip
10. Deed Book No, 2081 Page No.0285 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(ies).
New Hanover County [e-mail]
Company Name E-mail Address
200 Division Dr. 200 Division Dr.
Current Mailing Address Current Street Address
Wilmington, NC 28401 Wilmington, NC 28401
City State Zip City State Zip
Phone: Office# 910-798-4338 Mobile#[phone]
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)

Continued from Item 1 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#

Continued from Items 9 & 10 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:
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 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.

(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.
Kevin E. Caison Facilities Project Manager
Type or print name Title or Authority
/72 47 V 3
Sihature Date
I, , a Notary Public of the County of Rod et-
State of North Carolina, hereby certify that_k Ca;50/1 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 day of S cP fe.iv bec' 20P4A-Cli•
Notary
My commission expires 03/0// D2(o
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STATE OF NORTH CAROLINA
COUNTY OF NEW HANOVER WARRANTY DEED
THIS DEED,made this the 13th day ef Septeaber ,1996,by and between
AMMONS NORTHCHASE CORPORATION, a North Cesolima Corporation(ham called
bdiVisiiro of the
of Nords Carolina,
(h der `Grantee),with a miming addressP�Chissmut Street,Wihntngton.NC 28401;
(why one or more persons,Ones or ). The designstion Grantor and(rramee as used
herein shall include said parties,then heirs,successors,and assigns,and shell include singular.pkual,
come,feminine or neuter as required by contest.
W ITNESSETH:
8 THAT the said Grantor,in consideration of the Sum of TEN DOLLARS(S10.00)and other
good and valuable considerations paid to it,receipt of which is hereby acknowledged,has bargained
and sold,and by these prnsaots does hereby grant,bargain.sell and convey tutu the said Grantee,the
following described lands looted in the Township ofCape Fear.County of New Hanover and State
of North Carolina and bring more partia►luly described as follows:
BEING all of Let 22,Section 1 B of the NORTHCHASE PARK OF COMMERCE,as the same is
shown on a map thereof recorded in Map Book 31 at Page 94 of the New Hanover County Registry.
TOGETHER WITH AND SOB,IECr TO that certain Declaration of Covenants for the
NorthChese Pale of Commerce recorded in Book 1491 at Page 1558, as said Lot 22 has been
subjected to the same by instrument recorded in the New Hanover County Registry;and the Grantor,
its successors and assigns hereby waive and release unto the Grantee,its successors and assigns all
rights to buy back the real property described herein,which rights were reserved by Grantor,its
successors and assigns by Article Xlll of the said Declaration recorded in Book 1491 at Page 1558
of said Registry.
TO HAVE AND TO HOLD the above described lands and premises.together with all and
sing the rigs,privileges,easements,tenements,duties,obligations mid appurtenances s thereruito
belonging,or in anywise appertaining unto the said Grantee,in fee simple FOREVER.
AND said Grantor covenants with the Gtaraee that the Grantor is seized of the said premises
in fee simple,has the right to convey the same in fee simple,that the title is marketable and free and
clear of all encumbrances,except as herein set forth,and except for 1996 ad valorem taxes which
shall be prorated to the date of losing and usual utility easements,Restrictive Covenants and rights-
of-way of record,and said Grantor will WARRANT and DEFEND the title to the same against the
lawful claims and demands of any and all persons whomsoever. ma canna tic os/nsrK
,.(7 16,.2_` Real Estate
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BOOK «yt
2081 0286
•
IN TESTIMONY WHEREOF, AMMONS NORTHCHASE COIU'ORATION,
Wars,has caused this Instnmatt to be executed In its empaale nose by its duly ands:rind
corporate s affixed,all the day and year Ent above wriuea.
.j��4¢ 0� eal A
PAMTIS NO=CORPORATION
=o• SEALa .
cam Pnesiaestt
kcz.11:
TI:SEAL] '96 SEP 13 AN 9 28
:ECO tU L►AND VERIFIED
MIRY SUE DOTS a"
REGISTER OF DEEDS
STATE OF NORTH CAROLINA NEW HANOVER CO.NC
COUNTY OF NEW HANYOVER
1, a Notary Public in and for the County and State aforesaid, c eitify that
Emily 8, Na t h e w s personally appeased before me this day and acknowledged that
she is the Assistam Seery of AMMONS NORTHCTIASE CORPORATION,a North Carolina
corporation,and that by authority duly given and as an act of the corporation,the foregoing
htstrumem was signed in its nal=by its Vice Resident, sealed with its corporate seal and
attested by herself as its Assistant Secretary. Witness my hand and official stamp or seal this
13th day of September , 1996
e Public
.t'1 •.., expizes: //-3 9-99
•'`,,,," NORTH CAROLINA
COUNTY OF NEW HANOVER
The foregoing certificate of 4&I kLd e S Notary Public,is certified
to be correct this +5 day o - 1996.
MARY SUE OOTS
r--.. New;:r• u County
Byr/ • Jor//ULU—)
Ikpay!