20140938 Ver 2_MCDC (Signed)_20180611 (2)

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The following questions provide direction in determining when the Depat�tment is
required to prepare environmental documents for state-funded consh•uction and
maintenance activities. Answer questions for Parts A tlu•ough C by checking either "Yes"
or "No". Complete Part D of the checklist when Minimum Criteria Rule categories #8,
#12(i), or #15 are used.
TIP Project No.: N/A
State Project No.: 17BP.14.R.126
Project Location: Bridge No. 162 on SR 1361 (Old NC 280) over Silver Creek,
Transylvania County, North Carolina
Project Description: Replace Bridge No. 162 with a 16' 4" W x 5' 11" H x 37' L
aluminum box culvert on existing location.
Anticipated Permit or Consultation Requirements: Nationwide Pertnit Number 14,
401 Water Quality Certification, and TVA 26a permit.
Special Project Information:
08/OS/t4 1 of4

PART A: MINIMUM CRITERIA
Item 1 to be completed by tlre Engineer.
1. Is the proposed project listed as a type aud class of activity allowed under
the Minimum Criteria Rule in which environinental documentation is not
required?
If the answer to number 1 is "no", H�en tlie project does not qualify as a
minimum criteria project. A state envi�rontnental assessment is required.
If yes, under which categoly? (9) Reconstruction of existin¢ crossrond or
rnilroad separations and existine stream crossin�s.
includine, but not limited to uiues, culverts, and
bridees•
If eitlzer categoiy #8, #12(i) or f� 15 is used complete Part D of this cl�ecldist.
PART B: MINIMUM CRITERIA EXCEPTIONS
Itenzs 2— 9 to be conzpleterl by the E�rgineer.
2. Could Yhe proposed activity cause significant changes in land use
concentrations Yhat would be expected Yo create adverse air quality
impacts?
3, Will the proposed activity have secondary impacts or cumulaYive impacts
that may result in a significant adverse impact to human health or the
environment?
4. Is the pcoposed activity of such an unusual natme or does the proposed
activity have such widespread implications, that an uncom�non concern
for its environmental effects has been expressed to the Depaitment7
YES NO
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Item 5-8 to be conzpleted by Divisio�a Enviroftmental Officer.
5. Does the proposed activiTy have a significant adverse effect on wetlands; � �
surface waters such as rivers, streams, and estuaries; parldands; prime or
unique agricultural lands; or areas of recognized sceitic, recreational,
archaeological, or historical value?
6. W�ll fhe proposed activiTy endanger the existence of a species on the
Depa�tment of Interior's threatened and endangered species list?
'7. Could tl�e proposed activity cause significant changes in land use
concentrations that would be expected to create adverse water quality or
ground water impacts?
08/OS/14 2 of4
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8, Is tlie proposed activity expected to have a significant adverse effect on
long-term recreational benefits or shellfish, finfish, wildlife, or their
natural habitats
YES NO
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If any questions 2 through 8 are answered "yes", the proposed project may not qualify as a
Minimum Criteria project A state environme�tal assessment (EA) may be required. For
assistance, contact:
Manager, Project Development and Environmental Analysis Branch
P. O. Box 25201
Raleigh, NC 27611
(919) 733 —3141
Fax: [phone]
PART C: COMPLIANCE WITH STATE AND FEDERAL REGULATIONS
Items 9- l2 to be conzp/eterl by Division Environnzental Officer.
9. Is a federally pirotected threatened or endangered species, or its
habitat, likely to be impacted by the proposed action?
10. Does the action require the placement of temporary or permanent
fill in waters of the United States?
11
12.
Does the project require the placement of a significant amount of
fill in high quality or relatively rare wetland ecosystems, such as
mountain bogs or pine savannahs?
Is the proposed action located in an Area of Environmental
Concern, as defined in the coastal Area Management Act?
Itenas 13 —1 S to be co�npleted by U:e E�zgineer.
13. Does the project require sh�eam relocation or channel changes?
Cultural Resources
14. Will the project have an "effecY' on a property or site listed on the
National Register of Histoiie Places7
I5. Will the proposed action require acquisition of additional right of
way from publicly owned parldand or recreational areas?
YES NO
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Questions in Part "C" are designed to assist the Engineer and the Division Environmental
Officer in determining whether a permit or consulYation with a state or federal resource
agency may be required. If any questions in Part "C" are answered "yes", follow the
appropriate peimitting procedures prior to beginning project construction.
OS/OS/14 3 of4

]PAgb'Il' IlD• (To be �ompleted vvhen ei4her ca��go� #� #1�(i), op #15 of the raales aa�e
used.
; d2ena.s d 6= 22 to be co�p[efed b,y IlFva.saor� Envd�overnese�ral_�fficer.
16. Project length:
17
T
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Right of Way width:
Project completion date:
Total acres of newly disturbed ground
surface:
20. Total acres of wetland 'unpacts:
21. Total linear feet of stream isnpacts:
22. Projectpurpose:
If Part D of the checklist is completed, send a copy of the entire checldist document to:
Don G. Lee
State Roadside Envisomnental Engineer
Mail Service Center 1557
Raleigh, NC 27699-1557
[phone]
Fax [phone]
Emai1: dlee@dot:state:nc:us
Reviewed by: � �' �/�
Josh B. Deyton, PE
Division 14 Bridge Mana ent Enguieer
�2��� ��
Marlc S. Dauis
Division 14 Environmental Supervisor
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