106 PA Screening Checklist Burnt Mill Road

Cultural Resources Programmatic Agreement Screening Checklist for Section 106
Project TIP: NA FA: NA WBS: 49907
Project Name: Burnt Mill Road County: Forsyth
Project Description: Replace existing pipe on Burnt Mill Road
Funding Source: State Lead Federal Agency: USACE
Permits Anticipated: reporting NW 3
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
(https://www.ncdcr.gov/about/history/division-historical-resources/gis-maps-and-data) should be reviewed for
NRHP Eligible or Listed Buildings, Districts, Objects, Sites, or Structures. Before checking "Unable to Determine",
efforts should be made to acquire any available information. If the answer to any question is "Yes" or "Unable to
Determine", 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 information is discovered.
Please reference "Appendix A Exempt Activities Under Section 106' 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
El
❑
❑
A.
B. Is this project directly related to other actions with individually
but
❑
Elinsignificant,
cumulatively significant environmental effects?
C. Are you aware of any concerns raised by the owner of a historic
for this
El❑
property or public controversy undertaking?
D. Locations of cemeteries have been found on the webservices?
(https://www.ncdcr. gov/abouVWstory/division-historical-re source s/gis-
El
❑
❑
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".
Amy Euliss �AIV- �� 7/27/23
Name (print)
Date