20211251 Ver 1_Signed_Cultural_Resources_form_Collinstown Road_20210819

Cultural Resources Programmatic Agreement Screening Checklist for Section 106
Project TIP: FA: WBS:
Project Name: County:
Project Description:
Funding Source: Lead Federal Agency:
Permits Anticipated:
Instructions:
NCDOT Project Managers, Project Engineers, or the Division Environmental Staff shall complete the following
checklist based upon knowledge of the project site and adjacent parcels. Webservices
(htt ps:l/www.ncdcr.gO\-/abouU history/divisio n-hi stor ical-resour ces/gis-maps-and -data) should be reviewed for
NRHP Eligible or Listed Buildings, Districts, Objects, Sites, or Structures. Before checking "Unable to Detennine",
efforts should be made to acquire any available infonnation. If the answer to any question is "Yes" or "Unable to
Detennine", the undertaking is subject to further historic preservation review by NCDOT Cultural Resources staff.
If answers to all the questions are "No", the undertaking will be considered to have Little Potential to Cause Effects
-Exempt Activities and excluded from further historic preservation review, until differing infonnation is discovered.
Please reference "Appendix A Exempt Activities Under Section I 06'' of the Programmatic Agreement for
Transportation Program in North Carolina prior to completion.
Yes No Unable to Determine
A.Would this activity have the potential to cause effects on historic
properties, assuming historic properties are present? See list in Appendix
A.
B.Is this project directly related to other actions with individually
insignificant, but cumulatively significant environmental effects?
C.Are you aware of any concerns raised by the owner of a historic
property or public controversy for this undertaking?
D.Locations of cemeteries have been found on the webservices?
(https://www.ncdcr.gov/about/history/di vision-historical-reso urces/gis-
maps-and-data)
By my signature, I certify that I have completed a site visit or am familiar with the specifics of the project and to the
best of my knowledge answers to the questions above are correct. I also understand that no further environmental
analysis is required at this time, as all of the answers are "No".
Name (print) Signature Date
NW-3, GC 4132
X
X
X
X
DF17009.2085013
Collinstown Road SR 1432 Stokes
Pipe Replacement with the addition of headwalls
federal USACE
Stephanie Braquet 8/16/2021