FS 2800-16a Notice of Completion of Geophysical Exploration Operatio

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
DEPARTMENT OF AGRICULTURE
FOREST SERVICE

BLM Form 3150-5
FS Form 2800-16a
(May 2006)

FORM APPROVED
OMB NO. 1004-0162
Expires: February 28, 2009
NOI Case File No.

NOTICE OF COMPLETION OF OIL AND GAS
GEOPHYSICAL EXPLORATION OPERATIONS
Lessee or Operator
Address
City
Zip Code

State
Phone No. (Include area code)

E-Mail Address

Geophysical Co. Representative
Address
City
Zip Code
Phone No. (Include area code)
Cellular Phone No. (Include area code)

State

1. If different from the Notice of Intent and Authorization to Conduct Oil and Gas Geophysical Exploration Operations (NOI), list the lands that you actually used for
geophysical activities. Describe the lands by Meridian, Township, Range, and Section(s), or metes and bounds as appropriate:

2. Miles of source line or acres of survey on: a. Your Lease

b. Other Federal lands

3. If your operations were different from those proposed in the approved NOI, attach shotpoint or field maps showing actual line locations and access routes. (The map(s)
must be a minimum scale of 1:24,000 (7 1/2-minute USGS quadrangle or equivalent.) The maps must indicate public lands you crossed.
4. Describe how you plugged any shotholes.

5. If the Bureau of Land Management (BLM) or the Forest Service (FS) requests it, attach a copy of the “Hole Plugging Log” describing each shothole, including
whether holes were wet or dry, the static water level, flowing holes, breached or caved holes, or lost hole locations.
6. Describe any surface disturbance and how you reclaimed it.

I C ERTIFY that the oil and gas explorations approved under the NOI were completed on
complied with all terms and conditions of the approved NOI.

(Printed Name of Authorized Company Representative)

(Title of Authorized Company Representative)

and that the operations
(Date)

(Signature of Authorized Company Representative)

(Date)

Title 18 U.S.C. Section 1001 and Title 43 U.S.C. Section 1212, make it a crime for any person knowingly and willfully to make to any Department or
agency of the United States any false, fictitious or fraudulent statements or representations as to any matter within its jurisdiction.
(Continued on page 2)

NOTICES
The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d) provide that you be furnished the following
information in connection with information required by this Notice of Completion of Oil and Gas Geophysical
Exploration Operations.
AUTHORITY: 30 U.S.C. 181 et seq.
PRINCIPAL PURPOSE: We use the information to process your Notice.
ROUTINE USES: (1) To determine that mitigating measures are made to protect the environment. (2) Transfer
to appropriate Federal agencies when concurrence is required prior to granting a right in public lands or
resources. (3) Information from the record and/or the record will be transferred to appropriate Federal, State,
local or foreign agencies when relevant to civil, criminal or regulatory investigations or prosecutions.
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the information is voluntary. If all the
information is not provided, your right to conduct geophysical exploration activities may be revoked.
The Paperwork Reduction Act of 1995 requires us to inform you that:
BLM will collect this information under 43 CFR 3150.
FS will collect this information under 36 CFR 251.15.
BLM/FS will use this information to process geophysical exploration notices.
Response to this request is required to obtain a benefit.
BLM would like you to know that you do not have to respond to this or any other Federal agency-sponsored
information collection unless it displays a currently valid OMB control number.
BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average 20 minutes
per response, including the time for reviewing instructions, gathering and maintaining data, and completing and
reviewing of the form. Direct comments regarding the burden estimate or any other aspect of this form to the
U.S. Department of the Interior, Bureau of Land Management (1004-0162), Bureau Information Collection
Clearance Officer (WO-630), 1849 C Street, N.W., Mail Stop 401 LS, Washington, D.C. 20240.

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(BLM Form 3150-5 and FS Form 2800-16a, page 2)