NCC230299_FRO Submitted_20230202

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act 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 KLRWS 20 mgd Water Treatment Plant Improvements
Z Location of land -disturbing activity: County Vance City or Township Middleburg Township
280 Regional Water Lane 36.435-78.354
Highway/Street Latitude(de���,ai degrees) Longltude(decimas degrees)
3. Approximate date land -disturbing activity will commence: Jan. 21 , 2023
4.
5.
Purpose of development (residential, commercial, industrial, institutional, etc.): public utility
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 17.2
6. Amount of fee enclosed: $1800.00 . 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Casey Byrd E-mail Address byrdem9edmsmith.com
Phone: Office # 803-758-8437 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Henderson 252-438-2142
Name
PO Box 1434
Current Mailing Address
Henderson, NC 27536
City
Phone: Office 4
134 Rose Avenue
Current Street Address
Henderson, NC 27536
State Zip City
State
NIA
Mobile #
Zip
494 rA
10. Deed Book No. Page No. 548 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.) !f 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 Henderson
Company Name
134 Rose Avenue
Current Mailing Address
Henderson, NC 27536
City State Zip
Phone: Office # 252-430-5701
[e-mail]
E-mail Address
134 Rose Avenue
Current Street Address
Henderson, NC 27536
City
Mobile # NIA
State
Zip
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowners 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
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.
E. Terrell Blackmon
Type or print na
Signature
Tracey Kimbrell
City Manager
Title or Authority
� a o �-
Date
a Notary Public of the County of
Vance
State of North Carolina, hereby certify that E• Terrell Blackmon 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
,Illlllllllillf,.',,
K I k4
NOTARY
PUBLIC
�C
,#milli 11000,00
29th day of November 2022
JAOO�j,t_
Notary
My commission expires 2 25

STATE OF NORTH CAROLINk }
D
COUT3TY OF VANCE }
THIS DEED, made and entered into this the day
Of � , 1974, by and between A LBERT F . HARRIS
and ,vrife, EFFIE L. HARRIS of Vance County, North Carolina,
Parties of the First Part, and the CITY OF HENDERSON., a municipal
corporation located in Vance County, Forth Carolina (with the
powers of eminent domain), Party of the Second Part,
WITNESSETH :
That the said Albert F. Harris and Effie L. Harris in
consideration of the sum of Thirty Six Thousand Five Hundred
Dollars ($36)500.00) and other valuable considerations to them
paid by the City of Henderson_, the receipt of which is hereby
acknowledged, have bargained and sold, and by these presents
do bargain, sell and convey unto the said City of Henderson, its
successors and assigns, a certain tract or parcel of land located
near State Road 1371 in Vance County, North Carolina, more parti-
cularly described as follows:
Begin at an iron stake located at the southeastern corner
ro
of Tract M 1242 acquired by the United States of America
'j°�
relative to Kerr Lake, said stake being located at Harris'
?
corner; run thence along the line of the united States of
America South 2° 40' 1211 East 1,$54670 feet to a new
:stake, new corner for Harris (said corner being further
located North 2° 40' 12" ��est 1.59.05 feet from an iron
,..rat=^�•.
stake, corner in Harris' line) ; run thence along a new
-i
line for Harris South 19° 8' 81' East 690.77 -feet to an
iron stake, ne.% corner for Harris; run thence along a new
z
line for Harris north 10° 51' 5211 East 1,290.25 feet to
x.
an iron stak:i3 , new corner for Harris; run thence along a
nUw line for Barris North 790 8' 8" est 530 feet to an
}.'
Mix.�
iron stake,n�;vr corner for Harris; run thence along a
no;v :ire foz Harris north 3 '° 23' 3 5" West 785.32 feet to
Q
t1le ' a ce of be, nnin:,. The same, conta.intng 27.839 acres
as snoomi on p:'.r_v. of ropcsLd regionallfater treatment
n ~.��;t e�z the l.;t�T of H nderson prepared by L. E. t-' ooten
.,
rs�snoM
8, Er, ;ineers, dated October 9, 1973

Deed.ri _._ � Pa ged
Also conveyed is a permanent easement for• access, ingress
and egress to and from said property From State Road 1371=
which easement may also be used for water transmission
mains and other utilities by the C4.ty of Henderson, w.ts
sucessors and assigns, ;which easement -is described as
follows:
Begin at an iron stake Located on the Erestern right of way
of State Road 1371, and 30 feet from the center thereof
(said stake being further located North.l° 551 50 t' East
355.5 feet From Harris' southern property line); from
said beginning point, run thence North 850 46t 4711 West
478.76 feet to a point; run thence North 720 29t 42" Vest
196.59 feet to a point; run thence North 520'gt West 104.38
feet to a point; run thence North 310 46t 18" Vest 206.80
..feet to a point; run thence North 550 27' 131' west 80.33
feet to a point;. run thence North 790 8' 81, West 20.23 feet
to an iron stake located at the southeastern corner of the
27.839-acre tract above conveyed; run thence along the
line of the 27.839-acre tract North 10" 51t 52,t. East 100
feet to an iron stake; run thence South 79° 81 $" East
42.14 feet to a point; run thence South 55° 27t 13" East
120.50 feet to a point; run thence South 31° 61 1$11 East
210.17 feet to a point; run thence South 520 1 East 69.59
feet to a point; run thence South 72° 29t 4211 East 166.34
feat to a. point; run thence South $5° 46.'_ 7tt East 468.68
feet to an iron stake Located on the ire -stern might of way
of State Road 1371; run thence along the western right of
way of State Road 1371, and 30 feet from the center thereof;
South 5" 7 t 31' Jest 100.01 feet to the place of beginning.
The same being 2.485 acres as shown on plat of property of
proposed regional water treatment plant of the City of
Henderson prepared by L. E. Wooten 8; .Company, Consulting
Engineers, dated October 93 1973.
The Parties of the First Part reserve the right for them-
selves, the Girl. Scouts of America, and their respective
successors in title, to use, with the Party of the Second
Part, the existing road (presently running through the
2.485"acre easement and near the southern boundary line of
the 27.839-acre tract), (or in lieu thereof, [at the option
of the City.of Henderson, its successors and assigns] any
road hereafter constructed near said location replacing
the same) for ingress, egress and access Ito their respective
properties.
Further conveyed is a permanent easement for access, ingress
and egress to and from said property and the proposed water
intake to be located on the properties of the John 11. Kerr
Reservoir, which easement may also be used for water tran5 -
mission mains and other utilities by the City of Henderson,
its successors and assigns, which easement shall extend
twenty feet on either, side of a center line described as
follows:
The beginning point is Located at a point in Harris' line
__ n A - _- __I__ _I_ ... ., —4.- 4 r i nnni-bid

Re-e-d P e
North 490 31 Vest 131.52 feet from an iron stake located
in Harrist line with the United States of America which
in turn is located North ?90 351 West 312.21 feet from
the iron stake Located at the southeastern corner of Tract
M,-1242 acquired by the United States of America relative
to Kerr Lake; from the beginning point so established, run
thence North 450 12' East 45 feet to a point; run thence
North 61' 55' East 142.63 feet to a point; run thence North
460 2' East 129.68 feet to a point; run thence North 640
57r East 81.80 feet to a point; run thence along the peri-
meter of a curve to the right having a radius of 83.15
feet for a distance of 122.05 feet to a point located in
an existing farm road; run thence along the existing farm
goad South 30' 57t East 199 feet to a point; continue thence
along the farm road South 41* 57' East 298.1.1 feet to a.
point•, continue thence along the farm road, and along the,
perimeter of a curve to the left having a radius of 1$9.91
feet for a distance of 97.78 feet to a point; continue
thence along the farm road South 710 27' East 120.06 feet
to a point; continue thence along said farm road,.and
along the perimeter of a curve to the left having a radius
of 147.29 feet, fora distance of 96,40 feet to a point;
continue thence along the farm road North 71' 3' East
79.83 feet; continue thence along the farm road, and along
a curve to the right having a radius of 87.81 feet, for a
distance of..,124.14 feet to a point; continue thence along
the farm road South 270 57' East 35.33 feet; continue thence
along the farm road, and along the perimeter of a curve to
the right having a radius of 114-95 feet, for a distance of
94.33 feet to a point.; run thence South 190 I+t Iest 190.57
feet to a point; run thence South 27' 36' iVest 205.36 feet
to a point located in the line of Harris with the 27.939R-
acre tract hereinbefore described (which point is located
South 7.9, $' 'V est 657.65 feet from the property line of
the United States of America). For further reference see
plat of easement for access road through the property of
I:rs. Frances Daniel Gardner to be sold to Albert F. Harris
prepared by honey & Newcomb, Engineers and Surveyors,
dated January 1974.
The Parties of the First Part reserve the right for them-
selves and their successors in title to use the existing
farm road located partially on the above easement ( or in
lieu thereof, [at the option of the City of Henderson,
its successors and assigns] any road hereafter construdzd
near said location replacing the same) for ingress, egress
and access to their respective properties, so long as the
sane does not interfere with the easement herein granted.
i4o to.bacco or other crop allotments are to be conveyed
hereb,r, all of the same being reserved by the Parties of
the First Part; the City of Henderson proposes to use the
properties herein acquired for non-agricultural. purposes.
F�.),,, further reference se.e deed to the Part yes of the First
T). -t from Fr �nces Daniel Gardner and husband, J. C. Gardner,
1 r n ry f i r^ nf, f.iiP i3F? 7 fii.£?i' of of Vnnae

Deed
The Pa-rti es of the First Part: reserve the right to re-
locate their tobacco barns .s set forth n the
extension
of Option_ dated June 24, 1974.
T. S . Kit;trell, Trustee, and "rs . prances J . Gardner,
Koteholder under that certain Deed of `gust recorded in Book 489
at Page 796, Vance County Registry, and T. P. Gholson, Trustee,
and Tar Heel Production Credit Association, Noteholder under
that certain, Deed of Trust recorded in Book 489 at Page 798,
Vance'- County Registry, join in the execution of this Deed to
release the above tract and easements from the operation of said
respective Deeds of Trust, but for no other purpose, it being
distinctly understood that in no other manner shall said.Deeds of
Trust be in any way affected.
TO HAVE AND TO HOLD the aforesaid tract or parcel of
land; and all privileges arid-appurt;enance� -tahereto belonging to
the said Party _6f the Second Fart, its successors and assigns, to
their only use and behoof in fee simple forever.
And the said Albert F. Harris and Effie L. Harris
covenant with the said Party of the Second Part, its successors
and assigns, that they are seized of said premises in fee and have -
the right to convey in fee simple; that the same are free and
clear from all encumbrances, and that they 1,1ill warrant and defend
the said title to the same against the claims of all persons
whomsoever.
IN TESTIMONY,' WHEREOF, the said Albert F . Harris and wife,
Effie L. Harris have hereunto set; their hands and seals this the
day and year first above vwi,tten '
�(SEA.L
Bert F. Harris
l
re.rni

fee
page
�� • r.f.fri.� L
;= SE AL •t
l
1934 `
STATE 'OF NORTH CAROLINA
COUNTY Or VANCE
(SEAL)
T. S Kittrell, Trustee
_(SEAL)
Frances J. ardner,, Noteholder
T. P. Gholson, Trustee
TAR HEEL PRODUCTION CREDIT ASSOCIATION
Noteholder
Assistant Secretary —Treasurer
,,,`•,,,,, I, c •, r� .-�1 NotaryPublic do herebycertify
��..•`1a_'i�yt F. Harri�s_and._w.fe-,. Effie L. Harrl s, personally appeared
phis day and acknowledged the due execution of they foregoing
CD
ae purposes therein expressed.
P��1.� ?± mess my hand and notarial. seal this day of4.4'
Notary Public
My commission expires: ,7-&/_
STATE OF WORTH CAROLINA
COUNTY OF VANCE
Notary Public, do hereby certify
tsat T. S. Ki.trel,l, Trustee, personally appeared before me this day
and ackno'71edged the due execution of the foregoing Deed .for the
urposes �herein expressed.
_, uness my hard and notarial. seal. this � day of ,
'7%4•
j
;;s �;''•,, Notary Public
My commission expires:%-�—
olARl-

Pa,
Deed .
d
STATE OF NORTH CAROLINA
COUNTY OF VANCE
Public:, do hereby certify
that Frances personally appeared before iT°e-,
thA'y a;,� and acknowledged the due execution of the foregoing Deed
., ,fXJ.L' G%' LAAposes therein expressed.
`,�.'• ' �tness my hand and notarial seal_ this o day of
_L)
,,,�'• •..tip-��.,, Notary Public
:....... ......,, Ply commission expires. � �✓ /- � � `�
STATE OF NORTH CAROLINA
COUNTY OF VANCE
S 72::� , NotaryPublic, do hereby certify
G o l son, Trustee, personally appeared before me this ,day
�,::�Oel 'ack',bwledged the due execution of the foregoing Deed for the
,; �R,s wherein expressed.
s=tees.>� F hand and notarial seal this,rday of
G : , G . .� 1074,
Notary ub i c
My commission. expires:
STATE OF NORTH CAROLINA
COUNTY OF VANCE
This is to certify that on the 9 d y of
1974, before me personally came Zr,�
with whom I am personally acquainted and who by me duly sworn Both
say that he is the Assistant Secretary -Treasurer of Tar Heel Production
Credit Association, the corporation described in -and which executed
the foregoing instrument; that he knowsthe common seal of said corpor-
ation, that the seal affixed to the foregoing instrument is the said
common seal of said corporation and the name of the corporation was
affixed thereto; that said Assistant Secretary -Treasurer subscribed
his name thereto and said common seal was affixed all byr,.A4.11&ity of
the Board of Directors of said corporation duly given. •�;•• :r_ '••.'
Witness my hand and notarial— a1 = �' ���,
Teo any Public=.,;�'";;..X_
14y commission expires:...,,. CLL
STATE OF NORTH CAROLINA, VANCE COUNTY
The foregoing certificates of.' -Ann M. Ellis, Notary Public of Vance
County, N. C., and Jo Ann Moss, Notary Public of Franklin County, N. C
are certified to be correct. This instrument was presented for.