NCC232976_FRO Submitted_20231010

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 Mushroom Meadow Mitigation Bank
`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).
2. Location of land-disturbing activity: County Caswell City or Township Milton
River Bend Road 36.534037 -79.243504
Highway/Street Latltude(decimaldegrees) Long ltude(decimaldegrees)
3. Approximate date land-disturbing activity will commence:
Stream&Wetland Restoration
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 35 Acres
6. Amount of fee enclosed: $3,500.00 . 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 ❑x Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Norton Webster E-mail Address [e-mail]
Phone: office# [phone] Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Larry T Burnett 434-822-6060 434-250-7693
Name Phone: Office# Mobile#
2400 Cavalier Road
Current Mailing Address Current Street Address
Ringgold VA 24586
City State Zip City State Zip
10. Deed Book No.599 Page No.791 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).
Eco Terra Partners, LLC [e-mail]
Company Name E-mail Address
117 Centrewest Court 117 Centrewest Court
Current Mailing Address Current Street Address
Cary NC, 27513 Cary NC, 27513
City State Zip City State Zip
Phone: office# [phone] 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:
Eco Terra Partners, LLC [e-mail]
Name of Registered Agent E-mail Address
117 Centrewest Court 117 Centrewest Court
Current Mailing Address Current Street Address
Cary NC, 27513 Cary NC, 27513
City State Zip City State Zip
Phone: Office# [phone] Mobile# [phone]
Norton Webster
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:
NA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
NA
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.
NA
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.
Norton Webster Vice President
Type or print name Title or Authority
3/14/23
Signat re Date
I, f.eeiii- /3 h, , a Notary Public of the County of W 4C
State of North Carolina, hereby certify that 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 /i day of /Matti , 20 Z3
m Notary
a�
My commission expires i4ei 7, 202}

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:
Larry T Burnett 434-822-6060 434-250-7693
Name Phone: Office# Mobile#
2400 Cavalier Road
Current Mailing Address Current Street Address
Ringgold VA 24586
City State Zip City State Zip
Deed Book No.599 Page No.1095 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,jecord::T.,,
Name ,a Phone: Office# Mobile#
Current MailitidtAedress 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.

1'1 V L L 1. V 1 U—L JJ V V lAl L L V 1 1 V 1 1 V L L y✓—U L LJ V V Ul L LV
Filed:05/11/2017 08:56:06 AM BOOK 599 PAGE 791(7) 336881
Ginny S.Mitchell,Register of Deeds ( II'I lll
Caswell County,NC
REAL ESTATE EXCISE TAX:$650.00 `. jet
CIA/At
41"34--
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax:S650.00
Parcel Identifier No.0106.01.00.0002.0000 Verified by County on the_ day of ,20
By:
MaiPBo.x to:Willard Ray Burnett,2400 Cavalier Road.Ringgold,VA 24536
Tbis instrument was prepared by:R.Lee Farmer,Attorney at Lair.P.O.Box 1600,Yanceyyille.NC 27379
Brief description for the Index:
THIS DEED made this 26th day of April,2017.by and between
GRANTOR GRANTEE
H.GLENN HUNT and wife COERTNEY HUNT LARR1 THOMAS BURNETT,SR.
(a one-half undivided interest as tenants in common)
and
43851 Ludlum Court WILLARD RAY BURNETT
Ashburn,VA 20147 (a one-half undivided interest as tenants in common)
2400 Cavalier Road,Ringgold,VA 24586
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,feminine or neuter as required h :ontext.
WITNESSETH.that the Grantor,for a valuable consideration paid by the Grantee,the receipt ofsshieh is hereby acknowledged,has and
b)these presents does grant,bargain.sell and cons ey unto the Grantee its fee simple.all that certain lot or parcel of land situated in
Milton Township.Caswell County,North Carolina.and Pittsylcania County.Virginia.and more particularly described as follows:
•See"EXHIBIT A"which is attached hereto and incorporated herein by reference.as if fully set our herein.for a more particular
description.
TITLE NOT EXAMINED
The property,hereinabose described was acquired by Grantor by instrument recorded in Book .page .
All or a portion of the property herein comeycd includes or X does not include the primary residence of a Grantor.
A map show ing the above described property is recorded in Plat Book .page
NC liar Aswcizmm Form No 3 r;1476.RC,vied 1 1^nlu
Printed hs Aereemeni tuih tlic Ni'liar As ociarion

X 1 V J— J_ ' 1 U. JJ'1 l.11 L L`.1 1 V V BK-5S9'A-G 79 OIL lD ocIr33e810 yam.1'
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all pris ileges and appurtenances thereto belonging to the Grantee in
fee simple.
And the Grantor covenants with the Grantee,that Grantor is seized ofthe premises in tee 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 foliossing exceptions:
a) The 2017 Caswell County.North Carolina and Pittsy Isania County.Virginia ad salorem taxes.
• b)Any and all rights of way.easements or restrictions of record.
c)Compliance with any local.county,state or federal government lass or regulation relative to environment.zoning.subdivision.
occupancy,use,construction or development of the subject property.
d)Any and all inaccuracies and discrepancies in boundaries or acreage which an accurate survey of the property may disclose.
TITLE NOT EXAMINED
IN WITNESS WHEREOF,the Grantor has duly executed the foregoing as of the day and year first above written.
_ (SEAL)
Pri Type Name:II.Glet i Hunt
(SEAL)
(SEAL;
By: PrintT)pc N con ney Hunt
+ootn MI r1/IIh,
(SEAL) . G CIA R�,y%. ISEAL)
PrinCType Name: Prim Type Namets• ,tT~.•'NOTARV •~'G
s PUSUC fit"
(SEAL) c _ REG./7111[N9{ s (SEAL)
Print Type Name&Title: _ Print Type Nam i, MYC.OMMMSION` J
's onr+onot.
COMMONWEALTH OF VIRGINIA,City:Countyof (Al reax • CIkM"+
I,the undersigned Notary Public of the County and State aforesaid.certify that H.GL `*-kiolitind wife COURTNEY
HUNT personally appeared before me this day and acknowledged7/tll due execution o'the fo evoinyg instrument for the purposes therein
expressed. Witness my hand and Notarial stamp or seal this_Ct(J _day of_ :2017.
(�My Commission Expires: 0°1._J�/�)�li�Z l r( .Notary Public
(Affix Seal) Notary's Printed or yped Name
NORTH CAROLINA.CASWELL COUNTY
PMIIIal le NOW N1 d the 1977 Sessbn taws d
8rfie g llrtl Carom,lid the foregoing(Isobel
baetinifett band MWd 1 nN
malleri:172Lier
if
WON&WOW
NC Dar Association Form No.1 1,776,Reeiscd%,1.Ir2I111i
Printed by Aereemen1 smith the NC Dar:\ssrkialion