NCC241291_FRO Submitted_20240513

Check if this project is ARPA-funded
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 Mills River WTP Miscellaneous Upgrades Phase II
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
City of Asheville Mills River WTP Phase II Rehabilitation
2. Location of land-disturbing activity: County Henderson City or Township Mills River
4037 Haywood Road 35.5681 85.5682
Highway/Street Latltude(decimai degrees) LongltUde(decimal degrees)
3. Approximate date land-disturbing activity will commence:October, 2023
City of Asheville Water Authority
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 13.9
6. Amount of fee enclosed: $ 1 '400 . 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Keiran Ryan E-mail Address [e-mail]
Phone: office# 9193253591 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
City of Asheville 828-271-6101 NA
Name Phone: Office# Mobile#
3374 North Folk Left Fork Road NA
Current Mailing Address Current Street Address
Black Mountain, NC, 28711 NA
City State Zip City State Zip
10. Deed Book No. 874 Page No.039 Provide a copy of the most current deed.

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w iiIIIIIII 'PREPARED BY+ AOYD A. MASSADEH, JR.
__ F i Prince, Youngblood&Massages
ro m ; / lak.lb Nir,1-1 41b. Irw1 F;+',._,a o..n"137h
.-t i.ti0., STATE OF NORTH CAROLINA 1 /� kt• p a (.Eire-) rer.
COUNTY OF HENDERSON DEED
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4:7,' THIS DEED, Made this 14th day of July, in the year of our Lord, one
51 f thousand nine hundred and ninety-five, between JOHN C. MQLEAN and wife, CATHLEEN
o- t•,--.`fir ` H. McLEAN, (hereinafter referred to as *party of the first part', whether
� 4.2r, M1 singular, plural, male or female), of the County of Henderson and the State of
North Carolina, and CITY OF ASHEVILLE, a North Carolina Municipal Corporation,
£ (hereinafter referred to as 'party o_`the second part", whether singular, plural,
male or female), with an address of c/o Asheville-Buncombe Water Authority, Post
Q}..•� -, Office Box 7148, Asheville, North Carolina, 28802.
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' tt-" Ott HITNESSETH ,
, N t That the said party of the first part, for and in consideration of the sum
t i; EZ t : of Ten Dollar* ($10.00) and Other Valuable Considerations in hand•paid by the
said party of the second part, the,receipt whereof ie hereby acknowledged, has
Bargained and Sold, Conveyed and Confirmed, and by these presents does Bargain
, and Sell and Convey and Confirm udto the said party of the second part, its
• successors and assigns forever,all the following described piece or parcel of
II?!illIIila land lying and being in the Township of Mills River, County of Henderson, and
43ac CD StateState of North Carolina, and known'end designated as follows, vizi
,: X S ci BEING all of that certain 327.147 acre tract of land as shown on that
o plat captioned *Survey for t.aheville-Buncombe Water Authority',
.. m o which plat is recorded in Slide 1960, of the Renderson County, NC
(-tiJ co Register's Office, reference o whiobtplat is hereby made for a more
ins particular description of,pa.,d property.
1. ^ The warranties contained in: this deed shall not apply to that
`�,� a portion of the above described property which in reflected and set
forth in Insert 1, Insert 2, and Insert 3 as said inserts are shown
. 1 £ on the above-referenced plat'
I
• -fi R TO HAVE AND TO HOLD THE SAME, Together with all hereditaments and
'. oryo , ! appurtenances thereunto in any wife appertaining, unto the said party of the
t
ai O J, ' second part, its successors and asnigne forever.
lk"3. And the said party of the first part does covenant with the said party of
the second part, its successors and assigns, as follows: FIRST, that the said •••
n C I = ( ' party of the first part is the caner and lawfully seized of said land and
premises. SECOND, that it has goad right and full power to convey-the same.
,'•^` THIRD, that the same are free fro& all incumbrances whatsoever. And, FOURTH,
lillilllill that the said party of the second part, its successors and assigns, shall quietly
'.i -- enjoy and possess the eases, and that the maid party of the first part, their
.tom'm p 'heirs, executors and administrators will forever warrant and defend the title to
h c7, the name against all lawful claims.
eau Q IN TESTIMONY WHEREOF, The said party of,the first part has hereunto set
• 1� \� their hands end seals this the day.- year. first above written.
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STATE OF NORTH CAROLINA
COUNTY OF HENDE 3ON ��
I, �Ctl.�✓ a Notary Public, in and for the
above County d State do hereby tify tiat JOHN C. McLEAN and wife, CATHI.BBN , •
H. MCLEAN, parecnally appeared fore me•this day and acknowledged the due
execution by than of the foregoing deed of conveyance. '
•
WITNESS my hand and notarial seal, tk.ie the , ii _ day of July, 1995. .
1 b
t,•_ 1 g 1 Note�Public
rf 111 cgtaiitili6 q'')'Axpiree t"Y[
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STATE OF NORTH CARC•LINA, COUNTY OF HEND ERB •"•
The foregoing certificate(a) of �-ii_a_ �, .
, Notary Publih (Notaries Public)
is/are certified to be correct. This inatrumtnt resented for rag titration and .
recorded in thi of ce this i't day of C , 19 at
,3. M. in Book c_, Page and ver f#
•
`Z REGISTER OF DEEDS ASSISTANT) ) '
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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).
City of Asheville - Water Resources [e-mail]
Company Name E-mail Address
PO Box 7148 70 Court Plaza
Current Mailing Address Current Street Address
Asheville, NC 28802 Asheville, NC 28801
City State Zip City State Zip
Phone: Office# 828-271-6105 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)

(0) 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.
Da 1/ /60 rm D i reG40( oc tjeke r 3iiti�C
Typ p)t na Title or Authority
OC --jOa. 3
Signature Date
I, ?s r& 4 IA3C,U RE_V , a Notary Public of the County of e0114 .ems
State of North Carolina, hereby certify that 1-TL.Jf ICI Wit I TUp 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 vo day of (yikrt_L , 20 023
BARBRA H WALKER o ary
Notary,Pu_¢Ile,North Carolina
B ih bmbe County My Commission Expires My commission expires Co.a l. .5_0 a:7
06/27/2027

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.