FS 2800-16 Notice of Intent and Authorization to Conduct Geophysica

BLM Form 3150-4
FS Form 2800-16
(March 2011)

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

FORM APPROVED
OMB NO, 1004-0162
Expires: May 31, 2012
NOI Case File No.

NOTICE OF INTENT AND AUTHORIZATION TO CONDUCT
OIL AND GAS GEOPHYSICAL EXPLORATION OPERATIONS
Project Name

Lessee or Operator
Address
City
Zip Code

Do you have a bond on file with the Agency?
Which Agency?

State
Phone No. (Include area code)

BLM

Yes

No

Forest Service

Bond No.

Bond Amount: $

E-Mail Address
Geophysical Co.

Geophysical Co. Representative

Address

Address
State

City
Zip Code

City

Phone No. (Include area code)

State

Zip Code
Phone No. (Include area code)
Cellular Phone No. (Include area code)

E-Mail Address
Local Rep./Party Chief

1. Legal Description: Give the legal and land description of the lands involved using Meridian, Township, Range, and Section(s), or metes and bounds as appropriate:

You must also submit a map with a minimum scale of one-half inch per mile showing the general area and project location. We recommend a 7 1/2-minute USGS
quadrangle or the scale commonly used in the area. For seismic operations, your maps should include source and receiver lines, surface ownership, and any Federal lands
under lease. When survey lines are along property boundaries between Federal and private lands, indicate which side of the line you will use.
2. Do you hold any Federal leases within the project area?
operations on your Federal lease.

Yes

No (If yes, indicate location and lease numbers on an attached map.) Note: There is no fee for

3. If you are proposing seismic exploration, how many miles of source line (2-D), or acres (3-D) (to the nearest 10 acres) of survey are on:
a. Your Federal Lease

b. Other Federal lands

How long will the project last?
4. When do you expect to start exploration?
Describe any of your critical time frames associated with the proposed project, such as equipment or contractor availability.

days.

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)

Description and Type of Operations (check all that apply):
a. Survey Type:

2-D

3-D

Gravity/Magnetic

Other (explain):

Describe the survey type:

Surface charge

b. Survey Method:

Shothole

Vibroseis

Other (explain):

What type and amount of explosives per source point will you use?
What shotpoint pattern and spacing will you use?

What will be the shothole depth?

Did you attach or display a diagram of the shotpoint pattern on the project map?

Yes

No

Describe the survey method:

c. Transport Method:

Vibrator Trucks

Pick-up Truck

Buggy/ATV

Backpack

Helicopter

Describe your transportation plans, including types and numbers of vehicles and how you will access the project area:

.

d. Operating Procedures--Describe your operating procedures. including how you will minimize surface impacts. Describe support facilities you need, such as helispots,
camps, or powder magazines; construction of roads or trails, proposed plugging procedures for shotholes; and general clean-up procedures:

(Continued on page 3)

(BLM Form 3150-4 and FS Form 2800-16, page 2)

1.

2.
3.

4.

5.
6.

Terms and Conditions
The Bureau of Land Management (BLM) or Forest Service (FS)
9. I must take all reasonable precautions to prevent and must suppress
(Agency) must approve any Surface disturbing activities in addition
fires. The Agency may specify in writing the fire prevention and
to those approved in this NOI, such as route changes, placement of
firefighting equipment I need. At my expense, I must extinguish all
magazines, towing with a tractor, blading, dozing, snow removal,
fires set or caused as a result of operations under this NOI and must
and vegetation removal. I must notify the Agency in writing of any
report all fires to the Agency.
changes in the original proposal and have Agency approval in
10.
I
must diligently protect from unnecessary damage United States land
writing for the changes before proceeding with them. Stacking
and
property covered by this NOI. I must pay the United States for
sourcepoints to avoid sensitive resources or areas does not require
any damage resulting from my or my agents' or employees' violation
prior Agency approval.
of the terms of this NOI or any law or regulation applicable to the
This NOI expires on
, unless
lands involved.
the Agency extends it in writing before that date.
11. I must store and handle powder magazines and explosives according
to U. S. Bureau of Alcohol, Tobacco and Firearms standards (see 27
I understand that this NOI does not grant any exclusive right to the
CFR Part 55). I must properly secure loaded shotholes.
described lands for geophysical exploration, or other purposes. The
land area described above is at all times subject to any other lawful
12. I must complete shothole plugging under Agency guidelines and the
uses by the United States, its lessees, permittees. licensees, and
guidelines of any other local, Federal or State regulatory authority.
assigns.
13. I must remove all materials and equipment I placed on the premises
days, but no more
I must notify the Agency at least
and restore the site to the Agency's satisfaction immediately after I
complete the project unless the Agency approves other arrangements.
than
, prior to initiating the project and entering
upon the public lands.
14. I must file a Notice of Completion (NOC) Form within 30 days after
completing operations and reclamation. If the location of the project
In the field, each seismic crew must have with it a copy of the
approved NOI and its terms and conditions.
is different from that in the approved NOI, I must submit a revised
map with the NOC (1:24,000 scale, where available), including
The Agency may suspend or terminate this NOI if there is a violation
source points.
of any of its conditions.

7.

I must suspend operations when the operations may unnecessarily
damage the surface, such as when rutting would occur due to wet

8.

I must indemnify the United States for any liability for damage to life
or property resulting from the occupancy or use of public lands
under the NOI.

15.

soil conditions.

I must pay to the United States $
per
regulations.

according to the

16. This geophysical exploration project is subject to the attached
through
Conditions of Approval
and Exhibits

. C.
WARNING: If you purposely give false or misleading information, you maybe fined $10,000, sent to prison, or both (see Title 18 U.S.
1001 statement on page 1).
I agree that I and my agents must conduct the geophysical exploration under all Federal, State and local laws, and applicable regulations and must comply
with this NOI and any attached terms and conditions.
(Printed Name of Authorized Company Representative)
.
(Printed Name of Agency Signing Officer)

(Signature of Authorized Company Representative)

(Signature of Agency Signing Officer)

(Title of Agency Signing Officer)

(Date)

(Date)

NOTICES
The Privacy Act and 43 CFR 2.48(d) require that you be furnished with the following information in connection with information requested by this form.
AUTHORITY: The Mineral Leasing Act (30 U.S.C. 181 - 287), Mineral Leasing Act for Acquired Lands (30 U.S.C. 341 - 359), Federal Land Policy and Management Act of
1976 (43 U.S.C. 1701 - 1782), and National Environmental Policy Act (42 U.S.C. 4321 - 4347) permit collection of the information requested by this form. The BLM collects
this information in accordance with 43 CFR part 3150. The FS collects this information in accordance with 36 CFR part 228.
PRINCIPAL PURPOSE: The Bureau of Land Management (BLM) or the Forest Service (FS) will use the information to process your notice and inform you of the terms
and conditions under which geophysical exploration operations may be conducted.
ROUTINE USES: The BLM will only disclose the information in accordance with the Freedom of Information Act, the Privacy Act, and the provisions at
43 CFR 2.56(b) and (c). The FS will only disclose the information in accordance with the Freedom of Information Act, the Privacy Act, and the provisions at
36 CFR 200.7 and 7 CFR 1.1.
EFFECT OF NOT PROVIDING INFORMATION: Submission of the requested information is necessary to obtain or retain a benefit. Failure to submit
all of the requested information or to complete this form may result in delay or result in revocation of your right to conduct geophysical exploration
operations.
The Paperwork Reduction Act requires us to inform you that:
The BLM/FS collects this informaiton in accordance with the statutes and regulations listed above, and for the purposes listed above.
Submission of the requested information is necessary to obtain or retain a benefit.
You do not have to respond to this or any other Federal agency-sponsored information collection unless it displays a valid OMB Control Number.
BURDEN HOURS STATEMENT: The public reporting burden for this form is 1 hour per response, including the time for reviewing instructions, gathering and
maintaining data, and completing and reviewing the form. You may submit comments regarding the burden estimate or any other aspect of this form to:
U.S. Department of the Interior, Bureau of Land Management (1004-0162), Bureau Information Collection Clearance Officer (WO-630), 1849 C Street, N.W.,
Washington, D.C. 20240.

(BLM Form 3150-4 and FS Form 2800-16, page 3)