NCC232408_FRO Submitted_20230810

Check if this project is ARPA-funded
Attach a cnpv 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 Whitaker Park
"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).
2. Location of land-disturbing activity: County Forsyth City or Township Winston Salem
Highway/Street 951 Reynolds Boulevard Latitudedeamai degrees,36.1370 Longitude,deon»aI degrees,"80.2560
3. Approximate date land-disturbing activity will commence: January 16, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 8.00
6. Amount of fee enclosed: $900.00 . 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 I
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Travis Hayes E-mail Address [e-mail]
Phone: Office# [phone] Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners),
Cavalier Winston Development LLC 1-757-627-1980 1-757-544-1432
Name Phone: Office# Mobile#
300 West Freemason Street 300 West Freemason Street
Current Mailing Address Current Street Address
Norfolk VA 23510 Norfolk VA 23510
City State Zip City State Zip
10. Deed Book No. RE 3733 Page No. 1643-1647 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).
Cavalier Winston Development LLC [e-mail]
Company Name E-mail Address
300 West Freemason Street 300 West Freemason Street
Current Mailing Address Current Street Address
Norfolk VA 23510 Norfolk VA 23510
City State Zip City State Zip
Phone: Office# 1-757-627-1980 Mobile# [phone]
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:
Robert C Lawson
Name of Registered Agent E-mail Address
301 Fayetteville Street, Suite 1700 301 Fayetteville Street, Suite 1700
Current Mailing Address Current Street Address
Raleigh NC 27601 Raleigh NC 27601
City State Zip City State Zip
Phone: Office# 1-919-981-4072 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.
N/A
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.
Jeff Wermers VP of Construction
Type or print na e Title or Authority
August 9, 2023
S n re ✓ Date
Melissa J. Lewis , a Notary Public of the County of Forsyth
State of North Carolina, hereby certify that Jeff Wermers 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 9th day of August , 2023
O T ' � " Notary
N �
My commission expires September 5, 2023
;
�',, Ue L I C - -
CJ ;

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:
N/A
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:
N/A
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:
N/A
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:
N/A
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.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
N/A
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
N/A
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
N/A
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
N/A
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#

DUO& J,JJ ray C 104.,
2022055467 00210
FORSYTH COUNTY NC FEE$26.00
STATE OF NC REAL ESTATE EXTX
$9000.00
PRESENTED&RECORDED
12/16/2022 04:28:57 PM
LYNNE JOHNSON
REGISTER OF DEEDS
BY: CARLA B FLEMING, DPTY
BK: RE 3733
PG: 1643-1847
NORTH CAROLINA
SPECIAL WARRANTY DEED
FORSYTH COUNTY
Prepared hy: Kilpatrick Townsend&Stockton LLP(MAM) 1001 West Fourth Street. Winston-Salem.NC
27101-240O
Return to: Grantee
Brief Description tint the Index: j,ot 1 and I.ot ?, Plat Rook 67.Page 09
PIN:6837-10-3471 and 6837-10-9441
Excise Tax:5i'),0o0.00
TI lIS DEED made effective this lit day of December. 2022 by and between
GRANTOR GRANTEE
WPDA, INC.. CAVALIER WINSTON
a North Carolina non-profit DEVELOPMENT,LLC,
corporation a North Carolina limited liability
company
95 W. 32rd Street
Winston-Salem, NC 27105 M )West Freemason Street
Norfolk, VA 23510
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.
WITNESSETH. that Grantor, for and in consideration of the sum of Ten and No/100
Dollars ($10.00) and other good and valuable consideration in hand paid at and before the
delivery of these presents, the receipt and sufficiency of which arc hereby acknowledged. has
granted, bargained, sold, transferred, conveyed and confirmed and by these presents does grant,
bargain, sell, and convey unto the Grantee in fee simple, all that certain tract or parcel of land
lying and being in Forsyth County, North Carolina, being more particularly described on
EXHIBIT A (the"Property") attached hereto and incorporated herein by reference.
The Property hereinabove described was acquired by Grantor by instrument recorded in
Book 3340, Page 3252-3261, Forsyth County Registry.
submitted electronically by "Investors Title Insurance Company"
I' in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Forsyth County Register of Deeds.

DVV)t .)IJ.J Yayel 1V44
This property is subject to the Brownfields Agreement attached as Exhibit A to the
Notice of Brownfields Property recorded in Forsyth County land records in Book 3509, Page
468.
The Property herein conveyed does not include the primacy residence of Grantor.
TO HAVE AND TO HOLD the aforesaid Property and all privileges and appurtenances
thereto belonging to the Grantee in fee simple.
And Grantor covenants with Grantee, that Grantor has done nothing to title to impair
such title as Grantor received, and Grantor will warrant and defend the title against the lawful
claims of all persons claiming by, under or through Grantor, except for the exceptions hereinafter
stated.
Title to the Property is subject to the Permitted Exceptions as described on EXHIBIT B
attached hereto and made apart hereof. Notwithstanding the foregoing, the particular restriction
prohibiting animals from residing in the Whitaker Park Development as set forth in Section 2.5
of the Amended and Restated Master Declaration of Covenants between R.J. Reynolds Tobacco
Company and Grantor dated April 7, 2017 and recorded in Book 3340, Page 3234-3251 does not
prohibit domesticated animals(e.g.,dogs or cats) from residing or being permitted on any part of
the Property.
[Signature page.fallows]
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DUUJ. raya 10.4J
•
IN WITNESS WIIEREOF, Grantor has caused this instrument to be signed in its name
and delivered as of the date indicated on the first page of this Deed.
GRANTOR:
WPDA, INC.,
a North Carolina non-profit corporation
By: < _
Name: R ert E. eak, .
Title: •esident
STATE OF NORTH CAROLINA
COUNTY OF FORSYTI I
I certify that the following person 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 above: Robert E. Leak, Jr., President of'WPDA, Inc.
Date: December 2022
Notary Public
My Commission Expires: Print Name: 8s \CLS��
[Affix Notary Stamp or Seal]
TGYCE F., SOUTHERN
Notary Public- North Carolina
Forsyth County
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DUUA JIJJ ray= 104U
EXHIBIT A
Legal Description of the Property
All that parcel of land located in Forsyth County, North Carolina specifically described as
follows:
Being all of Lot 1, approximately 5.8402 acres, and Lot 2,approximately 2.7782 acres, as
shown on that Plat entitled"WPDA, Inc. Whitaker Park 2-1 and 2-2"dated December 7,
2017 and recorded in Mat Book 67, Page 69, Forsyth County Register of Deeds.
Together with the rights and privileges for access as shown on plat !Wok 7t, at I'agc (,t,,
Forsyth County Register of Deeds.
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auuw .>IJJ rays ivy
EXHIBIT B
PERMITTED EXCEPTIONS
1. Taxes and assessments for the year 2022 and subsequent years, not yet due and payable.
2. Unrecorded Donation Agreement between R.J. Reynolds Tobacco Company and the Landlord
dated January 5, 2015, as amended and modified by that First Amendment to Donation
Agreement dated April 7, 2017.
3. All matters which would be disclosed by a recent and accurate survey of the Property.
4. Portions of the Property that lie within the boundaries of public right of ways.
5. Municipal,zoning and subdivision laws and ordinances affecting the Property.
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