FS 2800-16a Notice of Completion of Oil and Gas Geophysical Explorat

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

BLM Form 3150-5
FS Form 2800-16a
(March 2011)

FORM APPROVED
OMB NO. 1004-0162
Expires: May 31, 2012
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)

(Date)

and that the operations

(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 and 43 C FR 2.48(d) require that you be furnished with the following information in connection
with the information required 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 Forest Service (FS) will use the
information you provide to determine when oil and gas exploration operations are completed and to determine that
mitigating measures are performed to protect the environment.
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 revocation of your right to conduct geophysical exploration operations.
The Paperwork Reduction Act requires us to inform you that:
The BLM/FS collects this information 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.
BLM/FS will use this information to process geophysical exploration notices.
Response to this request is required to obtain 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 estimated to average 20 minutes
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.

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