20231700 Ver 1_231212 farris combined pcn_20231212

12/12/23, 10:58AM wetlands-waters.com Mail - Fwd: SAW-2023-01885 Inman Road, Pilot Mountain UA
WR5WETLANChris Huysman <[e-mail]>
-
WATE. INC.
Fwd: SAW-2023-01885 Inman Road, Pilot Mountain UA
Chris Huysman <[e-mail]> Tue, Oct 31, 2023 at 7:49 AM
To: Drew Lucas <[e-mail]>, "Homer, Seren M" <[e-mail]>, JT Grimes
<[e-mail]>, [e-mail], "[e-mail]"
<Keith. Fardss@g mail. com>, Perry Isner <[e-mail]>
Seren-
We have spoken with the land owner and will be submitting an after -the -fact permit application for the road
crossing and a pond. The total impacts will not exceed 300 linear feet of streams. Our target date for the
PCN is December 5, 2023 and is pending the completion of drawings that are needed for the application;
they will be prepared by the engineer that is working on the project.
Please forward your site photos when you can and let us know which dates you were on site as we are
trying to understand the magnitude off -site sedimentation. As discussed, we found two off -site areas
upstream of the livestock watering area that are in need of remediation. The land owner wants to
immediately rectify the situation using a "bucket brigade" and this could happen in the next week or so
pending your consent. We observed dramatic morphological changes in the stream where the livestock
have access and our assessment is that much of the sediment in this area comes from the immediately
surrounding land use.
Seren and Jennifer -
Below is a screenshot of our delineation of the impacted areas of the property. We found that, but for the
installation of the pipes, the existing stream substantially follows the same flow path it has since the state's
lidar was generated. We noted that the vegetation has been altered, there are some equipment tracks, and
some sediment in the stream. We will generate a "landscaping plan" for enhancing that area once we better
understand the limits of the flooding from the pond.
Please do not hesitate to call or email with any questions that you might have.
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12/12/23, 10:58AM wetlands-waters.com Mail - Fwd: SAW-2023-01885 Inman Road, Pilot Mountain UA
[Quoted text hidden]
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D�0F INATEy
Office Use Only:
Corps action ID no.
DWQ project no.
Form Version 1.4 January 2009
Pre -Construction Notification (PCN) Form
A.
Applicant Information
1.
Processing
1a. Type(s) of approval sought from the Corps:
0 Section 404 Permit ❑ Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: 29 or General Permit (GP) number:
1 c.
Has the NWP or GP number been verified by the Corps?
❑ Yes 0 No
1d. Type(s) of approval sought from the DWQ (check all that apply):
0 401 Water Quality Certification — Regular ❑ Non-404 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorization
1 e.
Is this notification solely for the record
because written approval is not required?
For the record only for DWQ
401 Certification:
❑ Yes 0 No
For the record only for Corps Permit:
❑ Yes 0 No
1f.
Is payment into a mitigation bank or in -lieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation bank
or in -lieu fee program.
❑ Yes 0 No
1g.
Is the project located in any of NC's twenty coastal counties. If yes, answer 1h
below.
❑ Yes 0 No
1 h.
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes 0 No
2.
Project Information
2a.
Name of project:
Keith Farriss Pond
2b. County:
Stokes County
2c.
Nearest municipality / town:
Pilot Mountain
2d. Subdivision name:
N/A
2e.
NCDOT only, T.I.P. or state project no:
3.
Owner Information
3a.
Name(s) on Recorded Deed:
Chadbourn Keith Farriss
3b.
Deed Book and Page No.
0752 / 0759
3c.
Responsible Party (for LLC if
applicable):
3d. Street address:
11008 Vanguard Parkway
3e. City, state, zip:
Huntersville, North Carolina 28078
3f.
Telephone no.:
704.562.3202
3g.
Fax no.:
3h.
Email address:
[e-mail]
Page 1 of 10
PCN Form — Version 1.4 January 2009

4. Applicant Information (if different from owner)
4a. Applicant is:
❑ Agent ❑ Other, specify:
4b. Name:
4c. Business name
(if applicable):
4d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. Agent/Consultant Information (if applicable)
5a. Name:
Chris Huysman
5b. Business name
(if applicable):
Wetlands and Waters, Inc
5c. Street address:
170 Dew Drop Rd
5d. City, state, zip:
Sparta, NC 28675
5e. Telephone no.:
336.406.0906
5f. Fax no.:
5g. Email address:
chrishuysmant7a wetlands-waters.com
Page 2 of 10

B.
Project Information and Prior Project History
1.
Property Identification
1a.
Property identification no. (tax PIN or parcel ID):
5998135423.000
1 b.
Site coordinates (in decimal degrees):
Latitude: 36.44323 Longitude: 80.38804
1 c.
Property size:
17.3 acres
2.
Surface Waters
2a. Name of nearest body of water to proposed project:
UT North Double Creek
2b.
Water Quality Classification of nearest receiving water:
C
2c.
River basin:
Roanoke
3.
Project Description
3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application:
The project is a driveway and a pond that were constructed on an UT to North Double Creek. At this time the work is in the midst of being permitted
through DEMLR per the attached Erosion and Sediment Control Plan. The construction of the structure required a pre -construction notification due to
the conditions on the site. The site is located in a rural area in the foot hills of the piedmont of North Carolina.
3b.
List the total estimated acreage of all existing wetlands on the property: 0
3c.
List the total estimated linear feet of all existing streams (intermittent and perennial) on the property: 1490
3d. Explain the purpose of the proposed project:
The purpose of the driveway is to access high ground for the construction of a residence. The pond is aesthetic and incidental water for a hobby farm.
3e. Describe the overall project in detail, including the type of equipment to be used:
The overall project includes the construction of a residence and a hobby farm.
4.
Jurisdictional Determinations
4a.
Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (includingall prior phases)in the past?
❑ Yes X❑ No ❑ Unknown
Comments:
4b.
If the Corps made the jurisdictional determination, what type
of determination was made?
x❑ Preliminary ❑ Final
4c.
If yes, who delineated the jurisdictional areas?
Name (if known): Chris Huysman
Agency/Consultant Company: Wetlands and Waters, Inc
Other:
4d.
If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
5.
Project History
5a.
Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past?
❑Yes X❑ No ❑ Unknown
5b.
If yes, explain in detail according to "help file" instructions.
6.
Future Project Plans
6a.
Is this a phased project?
❑ Yes X❑ No
6b.
If yes, explain.
Page 3 of 10
PCN Form — Version 1.4 January 2009

C. Proposed Impacts Inventory
1. Impacts Summary
1a. Which sections were completed below for your project (check all that apply):
❑ Wetlands ❑X Streams —tributaries ❑ Buffers ❑ Open Waters X❑ Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a.
Wetland impact
number
Permanent (P) or
Temporary T
2b.
Type of impact
2c.
Type of wetland
2d.
Forested
2e.
Type of jurisdiction
Corps (404,10) or
DWQ (401, other)
2f.
Area of
impact
(acres)
W1
Choose one
Choose one
Yes/No
W2
Choose one
Choose one
Yes/No
W3
Choose one
Choose one
Yes/No
W4
Choose one
Choose one
Yes/No
W5
Choose one
Choose one
Yes/No
W6
Choose one
Choose one
Yes/No
2g. Total Wetland Impacts:
2h. Comments:
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a.
Stream impact
number
Permanent (P) or
Temporary (T)
3b.
Type of impact
3c.
Stream name
3d.
Perennial (PER) or
intermittent (INT)?
3e.
Type of
jurisdiction
3f.
Average
stream
width
(feet)
3g.
Impact
length
(linear
feet)
S1 P
Culvert
UT North Double Crk
PER
Corps
2.5
45
S2 T
Stabilization
UT North Double Crk
PER
Corps
2.5
8
S3 P
Dam construction
UT North Double Crk
PER
Corps
2.5
120
S4 T
Stabilization
UT North Double Crk
PER
Corps
2.5
8
S5 P
Flooding
UT North Double Crk
PER
Corps
2.5
135
S6 -
Choose one
3h. Total stream and tributary impacts
316
3i. Comments:
Impacts S1 and S2 relate to the construction of a driveway. Impacts S3, S4, and S5 relate to the construction of the pond. Impacts S2 and S4 are rip
rap stabilization that is pressed into the streambed.
Page 4 of 10
PCN Form — Version 1.4 January 2009

4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then indivi ually list all open water impacts below.
4a.
Open water
impact number
Permanent (P) or
Temporary T
4b.
Name of waterbody
(if applicable)
4c.
Type of impact
4d.
Waterbody
type
4e.
Area of impact (acres)
01
Choose one
Choose
02
Choose one
Choose
03
Choose one
Choose
04
Choose one
Choose
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If pond or lake construction proposed, the complete the chart below.
5a.
Pond ID number
5b.
Proposed use or
purpose of pond
5c.
Wetland Impacts (acres)
5d.
Stream Impacts (feet)
5e.
Upland
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
135
120
0
P2
Choose one
5f. Total:
5g. Comments: Impacts are enumerated in the stream impacts table
5h. Is a dam high hazard permit required?
❑ Yes 0 No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If any impacts require miti ation, then you MUST fill out Section D of this form.
6a. Project is in which protected basin?
❑ Neuse ❑ Tar -Pamlico ❑ Catawba ❑ Randleman ❑ Other:
6b.
Buffer Impact
number—
Permanent (P) or
Temporary T
6c.
Reason for impact
6d.
Stream name
6e.
Buffer
mitigation
required?
6f.
Zone 1
impact
(square
feet)
6g.
Zone 2
impact
(square
feet
131
Yes/No
132
Yes/No
B3
Yes/No
B4
Yes/No
B5
Yes/No
B6
Yes/No
6h. Total Buffer Impacts:
6i. Comments:
Page 5 of 10

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
The size of the pond has been reduced from its original contemplated size to be below mitigation requirements.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
Impacts have been avoided and minimized from the original contemplated size and configuration.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State?
❑ Yes X❑ No
2b. If yes, mitigation is required by (check all that apply):
❑ DWQ ❑ Corps
2c. If yes, which mitigation option will be used for this
project?
❑ Mitigation bank
El Payment to in -lieu fee program
❑ Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
3b. Credits Purchased (attach receipt and letter)
Type: Choose one
Type: Choose one
Type: Choose one
Quantity:
Quantity:
Quantity:
3c. Comments:
4. Complete if Making a Payment to In -lieu Fee Program
4a. Approval letter from in -lieu fee program is attached.
❑ Yes
4b. Stream mitigation requested:
linear feet
4c. If using stream mitigation, stream temperature:
Choose one
4d. Buffer mitigation requested (DWQ only):
square feet
4e. Riparian wetland mitigation requested:
acres
4f. Non -riparian wetland mitigation requested:
acres
4g. Coastal (tidal) wetland mitigation requested:
acres
4h. Comments:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 6 of 10
PCN Form — Version 1.4 January 2009

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires
❑ Yes ❑ No
buffer mitigation?
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.
6c.
6d.
6e.
Zone
Reason for impact
Total impact
Multiplier
Required mitigation
(square feet)
(square feet)
Zone 1
3 (2 for Catawba)
Zone 2
1.5
6f. Total buffer mitigation required:
6g. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in -lieu fee fund).
6h. Comments:
Page 7 of 10

E.
Stormwater Management and Diffuse Flow Plan (required by DWQ)
1.
Diffuse Flow Plan
1 a.
Does the project include or is it adjacent to protected riparian buffers identified
❑ Yes x❑ No
within one of the NC Riparian Buffer Protection Rules?
1 b.
If yes, then is a diffuse flow plan included? If no, explain why.
❑ Yes ❑ No
2.
Stormwater Management Plan
2a.
What is the overall percent imperviousness of this project?
1
2b.
Does this project require a Stormwater Management Plan?
❑ Yes X❑ No
2c.
If this project DOES NOT require a Stormwater Management Plan, explain why:
The
work does not increase impervious area.
2d.
If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
2e.
Who will be responsible for the review of the Stormwater Management Plan?
3.
Certified Local Government Stormwater Review
3a.
In which localgovernment's jurisdiction is thisproject?
❑ Phase II
❑ NSW
3b.
Which of the following locally -implemented stormwater management programs
❑ USMP
apply (check all that apply):
❑ Water Supply Watershed
❑ Other:
3c.
Has the approved Stormwater Management Plan with proof of approval been
❑Yes ❑ No
attached?
4.
DWQ Stormwater Program Review
❑Coastal counties
❑HQW
4a.
Which of the following state -implemented stormwater management programs apply
❑ORW
(check all that apply):
❑Session Law 2006-246
❑Other:
4b.
Has the approved Stormwater Management Plan with proof of approval been
❑ Yes ❑ No
attached?
5.
DWQ 401 Unit Stormwater Review
5a.
Does the Stormwater Management Plan meet the appropriate requirements?
❑ Yes ❑ No
5b.
Have all of the 401 Unit submittal requirements been met?
❑ Yes ❑ No
Page 8 of 10
PCN Form — Version 1.4 January 2009

F.
Supplementary Information
1.
Environmental Documentation (DWQ Requirement)
1 a.
Does the project involve an expenditure of public (federal/state/local) funds or the
❑ Yes X❑ No
use of public (federal/state) land?
1 b.
If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State
El Yes ❑ No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1 c.
If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
❑ Yes ❑ No
letter.)
Comments:
2.
Violations (DWQ Requirement)
2a.
Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ Surface Water or Wetland Standards,
X❑Yes ❑ No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b.
Is this an after -the -fact permit application?
ElYes ❑ No
2c.
If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
The land owner was unaware of the need to submit a pre -construction notification to construct a pond on private property. The grading contractor
commenced
the work and a sediment release resulted in a complaint to DWR. DWR noted the construction and the owner, once aware of the
situation, acted to stabilize the site.
3.
Cumulative Impacts (DWQ Requirement)
3a.
Will this project (based on past and reasonably anticipated future impacts) result in
El Yes X❑ No
additional development, which could impact nearby downstream water quality?
3b.
If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short narrative description.
4.
Sewage Disposal (DWQ Requirement)
4a.
Clearly detail the ultimate treatment methods and disposition (non -discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility.
N/A. The property has a single family residence with a septic system.
Page 9 of 10
PCN Form — Version 1.4 January 2009

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
habitat?
❑ Yes X❑ No
5b. Have you checked with the USFWS concerning Endangered Species Act
impacts?
❑ Yes x❑ No
5c. If yes, indicate the USFWS Field Office you have contacted.
-
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
Based on a review of PAC: Site is outside known range for regionally known protected species.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat?
❑ Yes X❑ No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
❑ Yes X❑ No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
SHPO CIS data shows no proximate sites or structures.
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain?
❑ Yes x❑ No
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination?
FEMA Floodplain mapper.
Applicant/Agent's Printed Name
Date
Applicant/Agent's Signature
(Agent's signature is valid only if an authorization
letter from the applicant isprovided.)
Page 10 of 10

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or ❑ yes ® No
habitat?
5b. Have you checked with the USFVIlS conceming Endangered Species Act ❑ Yes ® No
impacts?
5c. If yes, indicate the USFWS Field Office you have contacted.
5d. What data sources did you use to determine whether your site would impact Endangered Species or designated Critical
Habitat?
Based on a review of PAC: Sile is outside known range for regionally known protected species.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? ❑ Yes ® No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
govemments have designated as having historic or cultural preservation ❑ Yes © No
status (e_q- National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
SHPC GIS data shows no proximate sites or structures.
8, Fiood Zone Designation (Corps Requirement)
8a. W II this project occur in a FEMA-designated 100-year ffoodplain? ❑ Yes No
8b. If yes, explain how project meets FEMA requirements:
Sc. Mat source(s) did you use to make the floodplain determination?
FEIVA Floodplain mapper.
'~ Applicant/Agent's Signature Date
A�AntlAgent's Printed Name
(Agent's signature is valid only if an authorization
letter from the applicant is - Provided,)
Page 10 of 10

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SIN-20.07

BK 0752 PG 0759
Approved by Stokes County Tax Administration
NCGS 161-31(A) and NCGS 105-303(a2)
GAH Date 06/06/2022
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: $155.00
Parcel Identifier No. 5998135423 Verified by
By:
FILED ELECTRONICALLY
STOKES COUNTY NC
BRANDON HOOKER
REGISTER OF DEEDS
FILED Jun 06, 2022
AT 03:18 PM
BOOK 00752
START PAGE 0759
END PAGE 0761
INSTRUMENT # 03242
EXCISE TAX $155.00
County on the day of 20
Mail/Box to: Mark S. Rooster, Royster and Rooster, PLLC, PO Box 1396, Pilot Mtn., NC 27041
This instrument was prepared by: Royster and Royster, PLLC, PO Box 1396, Pilot Mtn., NC 27041
Brief description for the Index:
THIS DEED made this 27th day of May , 2022 , by and between
GRANTOR
Bobby C. Taylor, unmarried
205 Cherokee Hills Drive
Bassett, VA 24055
GRANTEE
Chadboum Keith Farriss and wife,
Minnette Gonzalez Farriss
11008 Vanguard Parkway
Huntersville, NC 28078
Enter in appropriate block for each Grantor and Grantee: name, mailing address, and, if appropriate, character of entity, e.g.
corporation or partnership.
The designation Grantor and Grantee as used herein shall include said parties, their heirs, successors, and assigns, and shall include singular,
plural, masculine, fenunine 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, parcel of land or condonunium unit
situated in the City of Quaker Gap Township, Stokes County,
North Carolina and more particularly described as follows:
See Exhibit "A" attached hereto and incorporated herein by reference.
The property hereinabove described was acquired by Grantor by instrument recorded in Book 407 page 741
All or a portion of the property herein conveyed _ includes or X does not include the primary residence of a Grantor.
A map showing the above described property is recorded in Plat Book 5 page 103
Page 1 of 2
NC Bar Association Form No. 3 O 1976. Revised © 1977, 2002, 2013 This standard form has been approved by:
Printed by Agreement with the NC Bar Association — 1981 North Carolina Bar Association — NC Bar Form No. 3
submitted electronically by "Royster and Royster, PLLC"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the stokes County Register of Deeds.

BK 0752 PG 0760
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:
IN WITNESS WHEREOF, the Grantor has duly executed the foregoing as of the day and year first above written.
(Entity Name)
By:
Print/Type Name & Title:
By:
Print/'Type Name & Title:
By:
Print/Type Name & Title:
State of Virginia _ - County or City of
SEAL
Print/Type Name:
(SEAL)
Print/Type Name:
(SEAL)
Print/Type Name:
(SEAL)
Print/Type Name:
I, the undersigned Notary Public of the County or City of TCya nNg-N , r::) and State aforesaid, certify that
Bobby C. Taylor, unmarried personally appeared before me this day and acknowledged the due
execution of the foregoing instrument for the purposes therein expressed. Witness my hand and Notarial stamp or seal this 27th day of
May , 20 22• -
My Commission Expires:
(Affix Seal)
SALLIE H. DEACON
NOTARY PUBLIC
Commonwealth of Virginia
Reg. #7377316
Commission Expires Feb. 28, 20
s Printed or Typed Name
Public
State of - County or City of
I, the undersigned Notary Public of the County or City of and State aforesaid, certify that
personally appeared before me this day and acknowledged the due
execution of the foregoing instruunent for the purposes therein expressed. Witness my hand and Notarial stamp or seal this day of
, 20_.
My Commission Expires:
(Affix Seal)
Notary Public
Notary's Printed or Typed Name
State of - County or City of
1, the undersigned Notary Public of the County or City of and State aforesaid, certify that
he is the
of
personally came before me this day and acknowledged that
a North Carolina or
corporation/limited liability company/general partnership/limited partnership (strike through the
inapplicable), and that by authority duly given and as the act of such entity, he signed the foregoing instrument in its name on its
behalf as its act and deed. Witness my hand and Notarial stamp or seal, this day of , 20_
My Commission Expires: Notary Public
(Affix Seal) Notary's Printed or Typed Name
Page 2 of 2
NC liar Association Form No. 3 01976, Revised cO 1977, 2002, 2013 This standard form has been approved by:
Printed by Agreement with the NC Bar Association — 1981 North Carolina Bar Association — NC Bar Form No. 3

BK 0752 PG 0761
Exhibit "A"
Lying and being in Quaker Gap Township, Stokes County, North Carolina
and being all of Tract Three, containing 17.304 acres, as appears on plat
recorded in Plat Book 5, Page 103, Stokes County Registry.
The above tract is a portion of that property as appears of record in Book 407,
Page 741, Stokes County Registry and all of Stokes County Tax Parcel
5998135423.