NCC243698_FRO Submitted_20241202

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 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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Wilson
1. Project Name
2. Location of land-disturbing activity: CountyMoore City or TownshipAberdeen
Highway/Street 170 Autumn Ridge Latitude35.1861 Longitude-79'5341
3. Approximate date land-disturbing activity will commence:12/2/24
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):1
6. Amount of fee enclosed: $ 100 . The application fee of$100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac= $900.00).
7. Has an erosion and sediment control plan been filed? YesX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Karen Wilson E-mail [e-mail]
Telephone[phone] Cell# 253-414-8748 Fax# NA
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Karen Wilson/Scott Hasemeier 253-414-8748 NA
Name Telephone Fax Number
51 McMichael Drive 51 McMichael Drive
Current Mailing Address Current Street Address
Pinehurst, NC 28374 Pinehurst, NC 28374
City State Zip City State Zip
10. Deed Book No.4487 Page No.333-334 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.)If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Karen Wilson [e-mail]
Name E-mail Address
51 McMichael Drive 51 McMichael Drive
Current Mailing Address Current Street Address
Pinehurst, NC 28374 Pinehurst, NC 28374
City State Zip City State Zip
Telephone[phone] _ Fax Number NA

2. (a) If the Financial:, 'e Party is not a resident of North Carolina, give name and street address
of the designated I°: a Agent:
Name E-mail Address
Current Mailing Ad, Current Street Address
City Zip City State Zip
Telephone Fax Number
(b) If the Financial! ble Party is a Partnership or other person engaging in business under an
assumed name, at 'y of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corpora{ :me and street address of the Registered Agent:
Name of Registers, E-mail Address
Current Mailing Ads Current Street Address
City Zip City State Zip
Telephone Fax Number
The above informatio 'd correct to the best of my knowledge and belief and was provided
by me under oath (Ti ,st be signed by the Financially Responsible Person if an individual
or his attorney-in-fac ,n individual, by an officer, director, partner, or registered agent with
the authority to exec ments for the Financially Responsible Person). I agree to provide
corrected information ire be any change in the information provided herein.
Karen Wilson owner
Type or print name Title or Authority
11/27/24
Signature Date
I, ' e< , a Notary Public of the County of u akb,rleAy,e1
State of North Carolir certify that 1<cy-e,iii innh appeared
personally before me and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand anc ,al, this 7 day of IVy , 20.4
7/../Hines
ue Nota
North Caroline
,,s, e My commission expires d&/z7/ gD,27

•
FOR REGISTRATION
JudyOREGIStEn OF DEEDS : `\i
Mar
Moore County, NC
May 08, 2015 02:18:24 PM
Book 4487 Page 333-334
FEE' $26.00
NC REVENUE STAMP: $120.00
INSTRUMENT # 2015005747
litlitil\111611111
INSTRU Et1T # 201SNO5747
NORTH CAROLINA
GENERAL WARRANTY DEED
Excise Tax: 1 z.O =
Brief Description: Lot 10, Autumn Acres West
Mail after recording to:
This instrument was prepared by: Paul B. Trevarrow, PLLC, 760C NW Broad St., Southern Pines, NC 28387
THIS DEED made this L T& day of April , 2015 by and between
GRANTOR
Robert L. Edwards and wife,Dianne R. Edwards
960 Foxfire Road
Aberdeen,NC 28315
GRANTEE
Karen L.Wilson and Scott l lasemcier
51 McMichael Drive, Pinehurst, NC 28374
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 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 or parcel of land and more particularly described as follows:
Being all of Lot 10, Autumn Acres West Subdivision, as shown on a plat thereof recorded in the Office of
the Register of Deeds of Moore County, North Carolina in Plat Cabinet 16, Slide 314.
This conveyance is made subject to enforceable reservations, easements, restrictions and covenants of
record, matters shown on the above plat, ad valorem taxes for the current year, and zoning or other
municipal ordinances.