ࡱ> y|rstuvwx bjbj Sbb!!!$T)T!I1L(9L9Lbd`}l!qTa9xddxx9Lb46xr9Lbx9LY !||M<||,,&usdtuvusususyusususxxxxusususususususususb k: CE Documentation Form for Federal Aid Projects Complete the following form. Following a YES or NO response or where indicated, provide a description of the potential impact. Document all consultation with resource agencies. Attach all supporting documentation including descriptions of resources, type of impact expected, what measures were taken to avoid or minimize the impact, why the impact is not significant, and the source of information used to make these determinations. Use additional sheets to respond to questions, as needed. Refer to the Guidelines for Completing the CE Documentation Form for further direction or additional information for each resource listed below. Note: This form will be a permanent part of the NDOR and Project Sponsor project file along with supporting documentation. Block 1. Project Description and Design InformationDate: FORMTEXT      Project No. FORMTEXT      Control No. FORMTEXT      Project Sponsor: FORMTEXT      Project Contact (include name, phone number, street address and email address):  FORMTEXT      NDOR District: FORMTEXT       Project Name and Location (include county, township, municipality, etc.). Attach Project Vicinity map:  FORMTEXT       Latitude: FORMTEXT      Longitude: FORMTEXT      Section: FORMTEXT      Township: FORMTEXT      Range: FORMTEXT      Limits of Work:Start: FORMTEXT      End: FORMTEXT      Total Length: FORMTEXT       Project Description Include narrative to describe general project scope of work - include type of construction, logical termini, reasons why termini are  logical termini , setting, and distinct project features:  FORMTEXT      Purpose and Need for Project:  FORMTEXT       Design Criteria for Roadway:Functional Classification: FORMTEXT      Current ADT: FORMTEXT      vpd(20 FORMTEXT      )Design Year ADT: FORMTEXT      vpd(20 FORMTEXT      )DHV: FORMTEXT      Trucks: FORMTEXT      %Directional Distribution FORMTEXT      %Design Speed: FORMTEXT      Posted Speed: FORMTEXT      Setting:  FORMCHECKBOX  Urban   FORMCHECKBOX  Suburban   FORMCHECKBOX  RuralTopography: FORMCHECKBOX  Flat   FORMCHECKBOX  Rolling   FORMCHECKBOX  Other Explain:  FORMTEXT       Roadway Character (Existing and Proposed):ExistingProposedNumber of Lanes: FORMTEXT       FORMTEXT      Surface Type: FORMTEXT       FORMTEXT      Roadway Width (ft): FORMTEXT       FORMTEXT      Shoulder Width (ft): FORMTEXT       FORMTEXT      Median Width (ft): FORMTEXT       FORMTEXT      Clear zone (ft): FORMTEXT       FORMTEXT      Average ROW Width (ft): FORMTEXT       FORMTEXT      Design Exception Requested:  FORMCHECKBOX  Yes   FORMCHECKBOX  NoIf yes, explain:  FORMTEXT       Design Criteria for Bridges / Culverts (if known):ExistingProposedBridge Number: FORMTEXT      Sufficiency Rating: FORMTEXT       FORMTEXT      Estimated Remaining Life: FORMTEXT      Bridge Type: FORMTEXT       FORMTEXT      Number of Spans: FORMTEXT       FORMTEXT      Structure Length: FORMTEXT       FORMTEXT      Weight Restriction (ton): FORMTEXT       FORMTEXT      Height Restrictions (ft): FORMTEXT       FORMTEXT      Curb to Curb Width (ft): FORMTEXT       FORMTEXT      Shoulder Width (ft): FORMTEXT       FORMTEXT      Under Clearance (ft): FORMTEXT       FORMTEXT      Lateral Clearance (ft): FORMTEXT       FORMTEXT      Design Exception Requested:  FORMCHECKBOX  Yes   FORMCHECKBOX  NoIf yes, explain:  FORMTEXT      1a). STIP / MPO: Is the project in the State Transportation Improvement Program (STIP)?  FORMCHECKBOX  Yes   FORMCHECKBOX  NoIf yes: Phase: FORMTEXT      Date: FORMTEXT      If no, contact NDOR Planning and Location Studies Manager.Is the project in the most current Metropolitan Planning Organization (MPO) TransportationImprovement Program (TIP)?  FORMCHECKBOX  Yes   FORMCHECKBOX  NoIf yes: Phase: FORMTEXT      Date: FORMTEXT      If no, and within a metropolitan planning area, contact NDOR. Block 2. Alternatives Considered2) Were other alternatives considered for the proposed action? If YES, describe all reasonable alternatives considered including a description of the preferred:  FORMTEXT       Does the project impact wetlands, floodplains, Section 4(f) properties, or threatened and endangered species? If YES, describe all avoidance, minimization, and mitigation considered including a description of the preferred:  FORMTEXT       FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No Block 3. Right-of-Way, Relocations, Utility Coordination 3a) Will the proposed action require new right-of-way (ROW) or easement or temporary construction easement? If YES, provide the following information: Approximate area of temporary ROW/easement:  FORMTEXT       acre(s) Approximate area of permanent ROW/easement:  FORMTEXT       acre(s) Approximate number of parcels for temporary ROW/easement:  FORMTEXT       Approximate number of parcels of permanent ROW/easement:  FORMTEXT       Reason for ROW/easement:  FORMTEXT       Current Land Use:  FORMTEXT       Are there any anticipated donations of ROW? Will the project use any Public Park ROW? Is it anticipated that construction will require a borrow site, construction staging area for batch plant or equipment, or a waste site outside the project area? Provide additional information for questions answered yes:  FORMTEXT       FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No3b) Will the proposed action cause relocation of any residential homes, businesses, farms, or public institutions? NOTE: If relocations are anticipated, relocation services will need to be provided per the Uniform Relocation Assistance Act. If YES, indicate the following: Number of displacements: Residential:  FORMTEXT       Businesses:  FORMTEXT       Farms:  FORMTEXT       Public Institutions:  FORMTEXT       Discuss displacements: Are there properties within the local area available for relocation? If YES, describe:  FORMTEXT       Will the project induce impacts to economic activity that is not authorized for reimburseable under state eminent domain? If Yes, explain:  FORMTEXT       FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No3c) Will the proposed action need to accommodate for utilities in the study area? If YES, state type of utilities and anticipated work involved (e.g., relocation, temporary disruption of service). Note if utility providers have been consulted. If known, indicate if utility crossing(s) will have the potential to impact stream, open water, or wetlands, or if the proposed action will require clearing and grubbing by utilities:  FORMTEXT       FORMCHECKBOX  Yes   FORMCHECKBOX  No3d) Describe the involvement with any railroad (active or inactive) including all rail lines, crossing, bridges, or signals.  FORMTEXT      Block 4. Socio-Economic4a) Are the anticipated environmental impacts resulting from the proposed action likely to fall disproportionately on the minority and/or low income populations, including populations with Limited English Proficiency (LEP)? Will the proposed project increase traffic in low-income and minority neighborhoods? Will minority owned businesses that serve a minority or low-income population be impacted by the project? Will access from minority or low-income neighborhoods to various services or cultural destinations (church, parks, community center) be affected by the proposed project? Will the project require displacement of any minority or low-income residences? Are there noise or air quality impacts to minority or low income populations? If YES, describe any potential adverse effects and the affected population (e.g., minority, low-income, elderly, or disabled), and describe proposed measures to mitigate for any adverse impacts:  FORMTEXT        FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No4b) Will the proposed action require temporary and/or permanent access changes? If YES, describe the access changes (temporary or permanent) and impacts to businesses (disruption, loss or restricted parking), residential neighborhoods, or individual residents:  FORMTEXT        FORMCHECKBOX  Yes   FORMCHECKBOX  No4c) Will the proposed action have an impact on travel patterns (e.g., does the action include a bypass or convert a local street into a higher order roadway)? If YES, describe any permanent traffic diversion or change of traffic patterns that would occur:  FORMTEXT       FORMCHECKBOX  Yes   FORMCHECKBOX  No4d) Is the proposed action consistent with local land use plans? If YES, identify area plans and assess consistency:  FORMTEXT       If NO, provide details of coordination with local government:  FORMTEXT       FORMCHECKBOX  Yes   FORMCHECKBOX  No4e) Will the proposed action cause economic impacts (temporary or permanent, positive or negative) to the local economy (e.g., adjacent highway-related and other businesses, employment gains or losses, etc.), local tax base or property values? If YES, describe impacts and any proposed measures to minimize economic impacts:  FORMTEXT       FORMCHECKBOX  Yes   FORMCHECKBOX  No4f) Will the proposed action result in impacts on fire, police, emergency services, health and educational facilities, school bus route, religious institutions, public transportation, or pedestrian and bicycle facilities? If YES, describe impacts and any proposed measures to minimize impacts:  FORMTEXT        FORMCHECKBOX  Yes   FORMCHECKBOX  No4g) Will the proposed action result in impacts to community cohesion (e.g., separation from community facilities or isolated portions of a neighborhood)? If YES, describe impacts and any proposed measures to minimize community division or separation:  FORMTEXT        FORMCHECKBOX  Yes   FORMCHECKBOX  No4h) Will the proposed action induce secondary growth? If Yes, explain:  FORMTEXT       FORMCHECKBOX  Yes   FORMCHECKBOX  No4i) Does the project incorporate bicycle or pedestrian facilities into the overall design or operations. If Yes, explain:  FORMTEXT       FORMCHECKBOX  Yes   FORMCHECKBOX  NoBlock 5. Historic and Cultural Resources (Section 106) (SHPO CONCURRENCE REQUIRED)5) Will the proposed action have an effect on historic, cultural, burial, or archaeological resources, including historic bridges or roads (e.g., Old Lincoln Highway), that are eligible for or listed in the National Register of Historic Places (NRHP)? If YES: Describe properties or resources impacted by project:  FORMTEXT       FORMCHECKBOX  Yes   FORMCHECKBOX  No NOTE: Project Sponsor will need to complete Section 106 consultation & documentation separately from the CE Process. Presence Level of Effects Not Present Potentially Eligible Resource Present Eligible Resource Present Listed Resource Present No Historic Properties Affected No Adverse Effect Adverse Effect Cultural Resources  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes Prehistoric Archaeology  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes Historic Archaeology  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes Historic Structure  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes Historic District  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes Historic Transportation Corridor  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  FORMCHECKBOX Yes  Is SHPO Coordination Complete? Attach concurrence letter: Date received:  FORMTEXT       NOTE: If Section 106 consultation results in an  adverse effect finding, then additional consultation will be needed.  FORMCHECKBOX  Yes   FORMCHECKBOX  No Block 6. Section 4(f) and Section 6(f) (FHWA APPROVAL REQUIRED) 6a) Will the proposed action have a constructive use or a temporary or permanent occupancy of any Section 4(f) resource (publicly owned parks, recreation areas, and wildlife/waterfowl refuges, and NRHP eligible or listed historic properties)? Avoidance is always preferred. If YES, a Section 4(f) individual, programmatic, or de minimis evaluation will need to be prepared. Consult with NDOR / FHWA to determine appropriate 4(f) document. Describe all 4(f) mitigation alternatives, including variations in design, used to minimize impacts:  FORMTEXT       FORMCHECKBOX  Yes   FORMCHECKBOX  No NOTE: Project Sponsor will need to complete 4(f) documentation separately from the CE Process. NOTE: Section 4(f) has a public information component. Public meetings can contain multiple project topics and are independent of a LPAs regular business meetings and held at convenient times and location(s) for the public affected by the project. 6b) Does the proposed action require the use of any property (public recreation sites or facilities) protected by Section 6(f) of the Land & Water Conservation Fund Act (LWCFA)? If YES, describe any property that may be impacted that was purchased or improved through the LWCFA, size /acreage impacted, and the impact (e.g., temporary or permanent, conversion to non-recreation uses).  FORMTEXT       Concurrence from official with jurisdiction of resource obtained? Attach correspondence: Date received:  FORMTEXT       Is coordination with NGPC complete? Attach correspondence: Date received:  FORMTEXT       FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No NOTE: Project Sponsor will need to complete 6(f) documentation separately from the CE Process.Block 7. Threatened and Endangered Species (USFWS CONCURRENCE REQUIRED) 7a) Will the proposed action affect any federally or state-listed threatened or endangered species or protected critical habitat? If No, attach USFWS and NGPC letters of effect determination:  FORMTEXT       USFWS Date Received:  FORMTEXT       NGPC Date Received:  FORMTEXT       If Yes, provide a summary of the informal consultation with the USFWS and the NGPC (attach correspondence) and describe avoidance, minimizing, mitigation, and conservation measures taken. If a determination was made that adverse impacts may occur, contact NDOR for further guidance. NOTE: Summary of project commitments need to be described in Block 18b-Environmental Commitments. FORMCHECKBOX  No,  No effect  FORMCHECKBOX  Yes,  May affect, but not likely to adversely affect  FORMCHECKBOX  Yes,  May affect, and is likely to adversely affect  7b) Will the proposed action result in exposure of ground water from an area within the Platte River Basin (e.g., material borrow sites, road construction, etc.)? If Yes, coordinate with USFWS and Nebraska Department of Natural Resources (NDNR)/appropriate Natural Resource District (NRD). Attach USFWS and NGPC letters. USFWS Date Received:  FORMTEXT       NDNR Date Received:  FORMTEXT       NOTE: Summary of project commitments (BMPs offered by resource agency) need to be described in Block 18b-Environmental Commitments.  FORMCHECKBOX  Yes   FORMCHECKBOX  No7c) Will the proposed action address the agency recommendations under the following acts: Migratory Bird Treaty Act (MBTA)? Fish and Wildlife Coordination Act (FWCA)? Bald and Golden Eagle Protection Act (BGEPA)? If No, explain:  FORMTEXT        FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  NoNOTE: Project Sponsor will need to complete all Section 7 consultation & documentation separately from the CE Process.Block 8. Farmland 8) Does the proposed action involve acquisition of prime, unique, statewide or local important farmland or use of farmland that would be converted to non-agricultural use? If YES, Indicate the size of area impacted: Farmland:  FORMTEXT       acres Describe or attach: Farmland conversion impacts or coordination with the Natural Resources Conservation Service (NRCS) Farmland Conversion Impact Rating Sheet (Form AD-1006).  FORMCHECKBOX  Yes   FORMCHECKBOX  NoBlock 9. Wetlands / Waters of the U.S. / Waters of the State (Title 117)9a) If there are no wetlands, waters of the U.S. or waters of the State located within the study area, check  N/A : Individual/Organization that made the determination:  FORMTEXT       Date of Field Visit:  FORMTEXT       Are wetlands, waters of the U.S. or State present within the study area but will be avoided by construction? Discussion:  FORMTEXT       FORMCHECKBOX  N/A  FORMCHECKBOX  Yes   FORMCHECKBOX  No 9b) Does the proposed action involve impacts to wetlands (including isolated wetlands identified by NDEQ)? If YES, what is the total wetland area impacted:  FORMTEXT       acre(s) Presence Impacts Not Present Present No Yes Wetlands  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Open Water  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Vegetated Emergent  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Scrub Shrub  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Forested  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Rain Water Basin  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Saline  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Western Alkaline  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Discussion:  FORMTEXT       Documentation Wetland Determination Memo Wetland Delineation Report Individual Wetland Finding USACE Jurisdictional Determination (if declaring isolated wetlands) Mitigation Plan Attach aerial photo map or plan showing wetland areas for the study area.  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No 9c) Are stream(s) present within the project area? If YES, will the stream(s) be impacted? (i.e., work will occur below ordinary high watermark) Name stream(s) impacted:  FORMTEXT       Is the stream(s) identified as wild and scenic, national recreation, or listed on the National Rivers Inventory (NRI)? Is there impact(s) to navigable waters of the U.S (applicable to Missouri River only)? Is the stream(s) intermittent, ephemeral or perennial?  FORMTEXT       Is this stream(s) designated as State Water Resource Class A? What is the length of stream channel impact (linear feet)  FORMTEXT       Discussion:  FORMTEXT       Are there other surface waters present within the project area? If YES, will the water body (s) be impacted? 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&.0LNRX^z|ǻǻǻǻo^K%jh."CJOJQJU^J hbxh."CJOJQJ^JaJ%jTh."CJOJQJU^J%jh."CJOJQJU^J%jhhbxCJOJQJU^J%jhbxCJOJQJU^JhbxCJOJQJ^JjhbxCJOJQJU^JhPCJOJQJ^Jh."CJOJQJ^Jjh."CJOJQJU^J֜؜ܜ 248>@B^`djp~kX%j h."CJOJQJU^J%jh."CJOJQJU^J hbxh."CJOJQJ^JaJ%j,hbxCJOJQJU^J%jhbxCJOJQJU^JhbxCJOJQJ^JjhbxCJOJQJU^J%j@h."CJOJQJU^Jjh."CJOJQJU^Jh."CJOJQJ^JVX ($Ifgdbx (x$Ifgdbx$& #$/Ifb$gd\7 ĝƝʝН֝"(.JLPVXZ\^ӭ߫ӘӅvg[Lh5h%CJOJQJ^Jh~CJOJQJ^Jh5hWlCJOJQJ^Jh5hbxCJOJQJ^J%j hbxCJOJQJU^J%jz hbxCJOJQJU^JU%j hbxCJOJQJU^J%j hbxCJOJQJU^JhbxCJOJQJ^JjhbxCJOJQJU^J hbxhbxCJ OJQJ^JaJ  FORMCHECKBOX  Yes   FORMCHECKBOX  No  9d) Will the proposed action require the following permits under the Clean Water Act? Section 404 Nationwide Permit (USACE) Section 401 Individual Water Quality Certification (NDEQ) Has coordination with USACE and NDEQ been initiated? If YES, attach any coordination with USACE, NDEQ, or other applicable resource agency.  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No Water related permits such as Section 404 and 401 are acquired after approval of the CE during final design.  Block 10. Floodplains10a) Is the proposed action located within the 100-year base floodplain?  FORMCHECKBOX  Yes   FORMCHECKBOX  No10b) Will the proposed action cause an encroachment or impacts to the 100-year Zone A floodplain? If YES, describe potential impacts and include the Federal Emergency Management Agency (FEMA) map with the project location identified. Include any consultation with the local or county floodplain administrators or the NE Department of Natural Resources (DNR) for the project area:  FORMTEXT       If there are substantial encroachment to the 100-year floodplain, FHWA must be consulted. FORMCHECKBOX  Yes   FORMCHECKBOX  NoBlock 11. Regulated Materials 11a) Is there any known or potential contamination at the project site (e.g., previous land uses with possible hazardous waste involvement), or additional remediation work that has to be done regarding hazardous or contaminated material? Will a building (age) or insulated pipe possibly containing asbestos or lead based paint be removed as part of this project? If a bridge replacement is part of the proposed action, is there the potential that lead paint was used on the structure? Discussion:  FORMTEXT       NOTE: If YES, and there is the potential for CERCLA, SARA, RCRA, TSCA, UST/LUST, lead, or asbestos issues on the project, notify and consult with NDOR and FHWA.  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  11b) Will the project action impact any registered or known groundwater monitoring wells? If Yes, identify any groundwater monitoring wells in the right of way, in the adjacent right of way, and the owner of said wells.  FORMTEXT        FORMCHECKBOX  Yes   FORMCHECKBOX  NoNOTE: Disposal of construction waste and debris must be handled as per Standard Specifications Sections 201, 202.02(4), 203.01, 203.02 and NDOR s Special Provision addressing unexpected discoveries of hazardous waste during construction. Block 12. Air Quality / Noise12a) Is the proposed action in an air quality non-attainment or maintenance area?  FORMCHECKBOX  Yes   FORMCHECKBOX  No12b) Will the project involve the addition of one or more through lanes? Will the project involve a change in vehicle mix or speed? Will the project involve a change in vertical or horizontal alignment? Will the project involve new roadways or change the shielding effect of existing roadways? If YES to any of the questions above, then a noise analysis is warranted, provided there are noise sensitive land uses in the project area. Attach Noise Analysis to CE Form. FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No12c) If yes to any of the questions in 12b, are there possible sensitive noise receptors present? If Yes, how many noise sensitive receptors are within the proposed action area?  FORMTEXT       If Yes, what type(s) of noise sensitive receptors are present? List below:  FORMTEXT       Attach a map of the sensitive noise receptors. FORMCHECKBOX  Yes   FORMCHECKBOX  No 12d) If a noise analysis was performed, are the predicted noise levels approaching or exceeding noise abatement criteria stated in 23 CFR 772 Table 1 for the appropriate land use activity category? Will there be a substantial increase in decibels over existing level? If YES, describe impacts and mitigation measures, if applicable.  FORMTEXT        FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  NoNOTE: Mitigation for noise impacts has a public information component. Public meetings can contain multiple project topics and are independent of a LPA s regular business meetings and held at convenient times and location(s) for the public affected by the project.Block 13. Water Quality 13a) Indicate if any of the groundwater resources, drinking and/or non-drinking water resources listed below are present in the project area: Groundwater Resources: Well Head Protection Area Community Wells Residential Wells Drinking Water: Surface water intake structures Non-Drinking water: Agricultural groundwater wells and surface water intake structures Irrigation re-use pit; Irrigation canal; Storm water detention impoundments; Agricultural waste impoundments; Ground water connected wetlands & surface water Water Quality Impacts: For the resources marked Yes above, discuss the following. If the resource is present but will not be impacted, state how the impact will be avoided.  FORMTEXT       If an impact to water quality will occur, indicate which water resource will be impacted and list any mitigation measures proposed to minimize impacts.  FORMTEXT         FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No 13b) Does the proposed action require a NPDES storm water permit? (NPDES is required if disturbance areas is greater than 1 acre.)  FORMCHECKBOX  Yes   FORMCHECKBOX  NoNote: Water related permits such as NPDES can be acquired after approval of the CE during final design.  13c) Will the project require connection to: Existing storm water culvert system? Existing combined storm water and sanitary sewer system? Will the project create a new storm water outfall into an existing channel? If yes, provide additional information and approximate location(s).  FORMTEXT       Attach correspondence with NDEQ documenting compliance with water quality standards for project impacts to water resources.   FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  NoBlock 14. Wild and Scenic Rivers / Nationwide Rivers Inventory 14a) Will the project involve construction in, across, or adjacent to a river designated as a component of, or proposed for inclusion in the Wild and Scenic River System? (i.e. Is the project is within 1/2 mile of a protected river area) If YES, discuss or attach record of consultation with the responsible agency for managing the listed or study river:  FORMTEXT        FORMCHECKBOX  Yes   FORMCHECKBOX  No 14b) Will the project cross over a river or portion of river that is listed on the Nationwide Rivers Inventory (NRI)? If Yes, list in Block 18b the Best Management Practices or recommendations by NPS to be implemented to reduce impacts to these rivers. FORMCHECKBOX  Yes   FORMCHECKBOX  NoBlock 15. Construction Impacts15a) Will the proposed action involve construction-related impacts such as detours, lane/road closures, loss of parking, air quality impacts (dust), etc.? If YES, provide details of proposed measures to minimize impacts (erosion control, Best Management Practices, dust abatement).  FORMTEXT        FORMCHECKBOX  Yes   FORMCHECKBOX  No15b) Will the proposed action require temporary channel crossing structures such as shoofly, work platform, causeway, or crossing? If YES, provide details on temporary structure alternatives (type of structure, temporary impacts involved, how long needed, etc):  FORMTEXT       Are impacts caused by the: Installation before or during active aquatic life migration periods? Impacts to streambed or width of channel? Flow characteristics of the stream  frequency and duration of flow? If impacts are YES, provide mapping and photos showing following information: Identify maximum limits of impacts below the ordinary high water mark. Identify ordinary high water mark on photos. Identify maximum limits of impacts within the floodway. Identify any fringe or adjacent wetlands. Discussion:  FORMTEXT        FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No 15c) Maintenance of Traffic During Construction (if applicable) Is a temporary bridge proposed? Is a temporary roadway proposed? Will the project involve the use of a detour or require a ramp closure? Will provisions be made for access by emergency services? Will provisions be made for access by local traffic and so posted? Will provisions be made for through-traffic dependent of businesses? Will provisions be made to accommodate any local special events or festivals? Will the proposed Maintenance of Traffic substantially change the environmental consequences of the action? Is there controversy associated with the proposed method for maintenance of traffic? Are there impacts to bicycles or pedestrian routes? If YES to any of the above questions, provide additional discussion.  FORMTEXT       List in Block 18b the commitments or recommendations for maintenance of traffic to be implemented to reduce impacts.   FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No  FORMCHECKBOX  Yes   FORMCHECKBOX  No 15d) Detours Attach a detour map. Approximate length of detour:  FORMTEXT       Select the best description of the planned detour:  FORMTEXT       FORMCHECKBOX  Detour will use local roads with no improvements.  FORMCHECKBOX  Detour will involve improvements to local roads with no resulting impacts on safety or the environment.  FORMCHECKBOX  Detour will involve improvements to local roads and will impact safety and/or the environment.  FORMCHECKBOX  Detour will use only state owned road Describe impacts:  FORMTEXT      Block 16. Public Involvement 16a) Will the project involve controversy concerning community and /or natural resource impacts? Discussion:  FORMTEXT       FORMCHECKBOX  Yes   FORMCHECKBOX  No16b) Is a public information meeting held or tentatively planned? If YES, give Date & Location:  FORMTEXT       Discussion:  FORMTEXT        FORMCHECKBOX  Yes   FORMCHECKBOX  No NOTE: Project public meetings are independent of a LPA s regular business meetings and held at convenient times and location(s) for the public affected by the project.Block 17. Aesthetics and other values17a) Will the project be visually intrusive to the surrounding environment? If Yes, discuss.  FORMTEXT        FORMCHECKBOX  Yes   FORMCHECKBOX  No17b) Will the project provide multiple use opportunities? If Yes, discuss.  FORMTEXT        FORMCHECKBOX  Yes   FORMCHECKBOX  No Block 18. Permitting and Environmental Commitments 18a) Indicate whether the proposed action is likely to require actions by agencies listed above or by other Agencies (e.g., permits, approval) and attach correspondence.USACE Section 404 Permit FORMCHECKBOX  Yes   FORMCHECKBOX  NoFloodplain Development Permit FORMCHECKBOX  Yes   FORMCHECKBOX  NoNDEQ Section 401 Water Quality Certificate / Title 117 approval FORMCHECKBOX  Yes   FORMCHECKBOX  NoNDEQ NPDES / SWPPP FORMCHECKBOX  Yes   FORMCHECKBOX  NoSection 106  Historic and Culturally Significant Properties FORMCHECKBOX  Yes   FORMCHECKBOX  NoSection 4(f)  Parklands, Recreation Areas, Refuges, Historic FORMCHECKBOX  Yes   FORMCHECKBOX  NoSection 6(f)  Land & Water Conservation Funds  FORMCHECKBOX  Yes   FORMCHECKBOX  NoCoast Guard Permit FORMCHECKBOX  Yes   FORMCHECKBOX  NoLocal Building or Site Development Permits  FORMCHECKBOX  Yes   FORMCHECKBOX  NoLocal Clearing and Grubbing Permit FORMCHECKBOX  Yes   FORMCHECKBOX  NoErosion and Sediment Control Plan  FORMCHECKBOX  Yes   FORMCHECKBOX  No 18b) Environmental Commitments: Describe any measures, including Best Management Practices, recommended by resource agencies through informal consultation or those measures to be taken to mitigate project impacts. Include any environmental commitments agreed upon or those resources to be avoided. All commitments made and documented in this form are to be listed here.  FORMTEXT       Block 19. Approval FORMCHECKBOX  Wetland Finding- In compliance with Executive Order 11990,  Protection of Wetlands, and with 23 CFR 771, 23 CFR 777, it is determined that there is no practicable alternative to the proposed new construction in wetlands and that the proposed action includes all practicable measures to minimize harm to wetlands which may result from such use. As a result of environmental review, NDOR finds that this action does not: induce significant impacts to planned growth or land use for the area; require the relocation of significant numbers of people or businesses; have a significant impact on any natural, cultural, recreational, historic or other resource; involve significant air, noise, or water quality impacts; have significant impacts on travel patterns or otherwise, either individually or cumulatively. All other environmental coordination, consultation, and requirements have been satisfied. NDOR has determined that the proposed action has no significant impacts on the environment and that the proposed action is categorically excluded from the requirement to prepare an EA or EIS under the National Environmental Policy Act (NEPA). Based on the evaluation of all alternatives, it has been determined that there is no practicable alternative to the proposed construction and it includes all practicable measures to avoid or minimize impacts to wetlands and related resources that may result from such an action. Approvals: Prepared By: Name: FORMTEXT      Date: FORMTEXT      (print)(sign)Organization & Title: FORMTEXT      Phone: FORMTEXT      Email: FORMTEXT      Reviewed by Project Sponsor: [LPA = County or City Representative  other than Consultant]Name: FORMTEXT      Date: FORMTEXT      (print)(sign)Organization & Title: FORMTEXT      Reviewed by: FORMTEXT      Date: FORMTEXT      (print)(sign)Title: NDOR Environmental Documents Unit ManagerApproval: FORMTEXT      Date: FORMTEXT      (print)(sign)Title: NDOR Environmental Section ManagerFHWA Approval: FORMTEXT      Date: FORMTEXT      (print)(sign)Title: Transportation Engineer Enclosed Attachments  FORMCHECKBOX  Project Vicinity Map (State, local, and project maps)  FORMCHECKBOX  State Historic Preservation Office (SHPO) letter(s) of concurrence  FORMCHECKBOX  FHWA Section 4(f) approval documentation  FORMCHECKBOX  Nebraska Game and Parks Commission letter(s) of concurrence  FORMCHECKBOX  U.S. Fish and Wildlife Service letter(s) of concurrence  FORMCHECKBOX  U.S. Army Corps of Engineers / Clean Water Act correspondence  FORMCHECKBOX  Nebraska Department of Environmental Quality correspondence  FORMCHECKBOX  Natural Resource Conservation Service Farmland Conversion Form AD1006  FORMCHECKBOX  Tribal consultation letter(s)  FORMCHECKBOX  Other Agencies (e.g., USEPA, DNR, NPS, FAA, NRD, USCG-Missouri River only)     CE Documentation Form for Fed Aid Projects Nebraska Department of Roads Final Version; November 2008 CE DF- PAGE \* MERGEFORMAT 4 Final Version; November 2008 CE DF- PAGE \* MERGEFORMAT 3 XZ\ zoY?$& #$/7$8$H$If^b$gd\7$& #$/7$8$H$Ifb$gd\7 0$7$8$H$gd\7kdf $$Ifl0<' t 6 044 lae4ytM^` nʍ̍ 468:DJTҲҢ‚ҒҒo\oG;h%CJOJQJ^J(h5h%5B*CJOJQJ^Jph%h5hs2(B*CJOJQJ^Jph%h5hjgB*CJOJQJ^Jphh(Ehe^CJOJQJ\^Jh5he^CJOJQJ\^Jh5hYG1CJOJQJ\^Jh5hu-]CJOJQJ\^Jh(EhgCJOJQJ\^Jh5h%CJOJQJ\^Jh5h%CJOJQJ^Jh5h8 CJOJQJ^J Vʍ̍68BD ($Ifgdbx$& #$/Ifb$gd\7$& #$/7$8$H$Ifb$gd\7 & Fx$& #$/7$8$H$If^b$gd+ & F$& #$/7$8$H$If^b$gd+ 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