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

BLM Form 3150-5 FS Form 2800-16a (September 2013)	UNITED STATES DEPARTMENT OF THE INTERIOR BUREAU OF LAND MANAGEMENT DEPARTMENT OF AGRICULTURE FOREST SERVICE NOTICE OF COMPLETION OF OIL AND GAS GEOPHYSICAL EXPLORATION OPERATIONS								FORM APPROVED OMB NO. 1004-0162 Expires: July 31, 2015
									NOI Case File No.
									Project Name
Lessee or Operator				Geophysical Co. Representative
Address				Address
City			State	City					State
Zip Code		Phone No. (Include area code)		Zip Code		Phone No. (Include area code)
Representative’s Email Address				Cell Phone Number
1. If different from the Notice of Intent and Authorization to Conduct Oil and Gas Geophysical Exploration Operations (NOI), show the lands, line locations, shot points, and routes that you actually used for geophysical activities. To depict any deviations from what you had proposed in the approved NOI, we recommend a PDF version of a 7 1/2-minute USGS quadrangle or the USGS map scale commonly used in the area along with GIS data in a locally projected Universal Transverse Mercator (UTM) North American Datum (NAD) 1983 ESRI shape file or geodatabase format (e.g., UTM zone 13N NAD83). For seismic operations, your maps and GIS data must include the locations of operations and facilities planned in the NOI; and clearly attributed, the actual access routes to and within the project area, source and receiver point locations and lines, and shot point locations used in your geophysical operations where they deviate from those proposed in the NOI. The map and data must also include surface ownership and any Federal lands under lease. Explain deviations from the original NOI.
2. Miles of source line or acres of survey on: a. Your Lease _____________________________ b. Other Federal lands _________________________________
3. Describe how you plugged any shot holes.
4. .If the Bureau of Land Management (BLM) or the Forest Service (FS) requests it, attach a copy of the “Hole Plugging Log” describing each shot hole, including whether holes were wet or dry, the static water level, flowing holes, breached or caved holes, or lost hole locations.
5. Describe any surface disturbance and how you reclaimed it.
I CERTIFY that the oil and gas explorations approved under the NOI were completed on __________________________and that the operations complied with all terms and conditions of the approved NOI. (Date)
Printed Name of Authorized Company Representative					Signature of Authorized Company Representative
Title 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.

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NOTICES

The Privacy Act and 43 CFR 2.48(d) require that you be furnished the following information in connection with information request 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 parts 3150 and 3160. The FS collects this information in accordance with 36 CFR part 228.

PRINCIPAL PURPOSE: The BLM or the 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 currently 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), 1849 C Street, NW, Room 2134LM, Attention: Information Collection Clearance Officer, Washington, D. C. 20240.

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