Please supply the required information listed below. Additional information and/or supporting documentation may be required to complete the EA as determined by the BIA Osage Agency on a project specific basis.

1.	Who will be responsible for preparing the Environmental Assessment (EA)?  Select one of the following options.

Lessee Prepared EA: In order to streamline and expedite the approval of the EA and the issuance  of the  drilling permit by the Superintendent, the Lessee can opt to complete the EA and submit the document to the BIA for further review and/or approval. Once the EA has been finalized then a Finding of No Significant Impact (FONSI) and Notice of Availability will be completed by the Osage Agency and the EA document and decision-to-proceed will be made available for a 30-day public comment period. If no significant comments are received during the review period that impact the FONSI determination then the drilling permit can  be approved at that time. Optional: If desired, then an environmental consultant may be hired to prepare the EA  on behalf of the Lessee.

BIA Prepared EA: The BIA can prepare the EA on behalf of the Lessee if requested. However, the EAs will  be prepared according to the order in which the completed Application for Permit to Drill Form 139 was received by the Osage Agency. The amount of time needed for the BIA to prepare the EA would be dependent upon the current workload of the Agency and the total number of pending permit applications.  Once the EA  has been completed then the same process described above would be required to approve the EA, post the decision for public review and then issue the approved drilling permit.

2.	Who is the surface owner(s) for the proposed well location (25 CFR 226.18)? Provide any available contact information including address and phone numbers for these individuals.

3.	What are the latitude and longitude coordinates of the proposed well head?

4.	Drilling Plan (including, but not limited to the following):

a.	Give the name of the formations to be penetrated, as well as the estimated top and thickness of each formation.  Indicate all formations potentially containing useable water, oil, gas or other minerals (25  CFR
a.	

226.32 and 226.35). Specifically, identify any water-bearing formations (including depths) to be penetrated during drilling operations as these freshwater zones will require additional protective measures.

b.	Describe preventive measures and equipment to be utilized for blowout prevention (25 CFR 226.36).

c.	Specify the type of well to be drilled (i.e. oil, gas, horizontal or vertical). If horizontal, describe the directional design including bottom hole location.  Additional information may be needed if horizontal.

d.	Specify the approximate amount of sand propellant and barrels of water that will be used to fracture the well.

5.	Casing Program (25 CFR 226.35) including:

a.	Size, grade, weight, width and depth of the casing.  Also provide the diameter of the drilling hole size.

b.	Estimated setting depths of casing.

c.	Give the estimated amount and type of cement to be used in setting each casing string.

d.	Provide the amount and type of mud to be used and describe the location and size of any necessary drilling pits.  (25 CFR Part 226.22)

6.	Surface use plan including:

a.	Describe the access road (length and locations) and drilling pad (dimensions, acreage and location) and the construction methods to be used (25 CFR 226.19).

b.	Describe how surface water, groundwater and other environmental resources will be protected.

c.	Will Wetlands be impacted?  If yes, describe the anticipated impacts.

d.	Describe the agreement with the surface owner for ingress and egress of the site (25 CFR 226.18).

e.	Provide a sketch of the proposed drilling site including the well pad, well bore, and access roads (both permanent and temporary). The grid found below represents the 160-acre leased quarter section. Each square represents a 330’ by 330’ square area or 2.5 acres.

f.	Description and location of any off-location ancillary facilities (i.e. construction of a tank battery or flowlines). If the proposed well will be part of an existing tank battery facility then provide the legal description and name of the battery that will receive any production. Will the fluid(s) be comingled into  one line and separated at the tank battery or will they be transported in separate flow lines?

g.	Location and types of nearby water bodies (i.e. drainages, tributaries, creeks, streams, rivers, ponds, lakes). Give direction and approximate distance to all water bodies and known water wells that occur within a ½ mile radius of the proposed drilling location.

h.	Describe the Waste Management Plan to dispose of any wastes (i.e. trash/debris, drilling mud, cuttings, or other deleterious substances used in drilling activities) generated by the proposed drilling activity (25 CFR 226.22).  How will produced water be disposed of that is generated from the new well?

i.	Describe any plans for surface reclamation of the site (both interim and final), including soil stabilization and erosion control measures.

7.	Will the proposed well be producing to a brand new tank battery facility or to an existing facility? Select one of the options below and provide a copy of the required documentation.

If to a brand new facility then a draft Spill Pollution Control and Countermeasure (SPCC) Plan for the proposed tank battery facility must be submitted to the BIA for inclusion into the EA to describe how the  Lessee/Operator will respond to any incidental spill releases of brine or hydrocarbons as a result of production activities after the well has been drilled.

If to an existing tank battery facility then a final SPCC Plan should already exist that will cover the new well location. This final plan must be submitted to the BIA for inclusion into the EA for the same reasons described above.

8.	National Historic Preservation Act

a.	Has a cultural resources report been prepared for the proposed well? Yes/No.

b.	Will a request be submitted for the BIA Osage Agency to perform the cultural resources field survey and report? Yes/No.

c.	Has a contractor been selected to prepare the cultural resources report for the proposed well? If so, then what is the status of the report?  Has it been submitted to the Osage Agency for review?

9.	Endangered Species Act

a.	American burying beetle (if applicable) – If your proposed well is located within the range of the endangered American burying beetle (ABB) and if your project area is considered suitable habitat for the ABB, then one of the following mitigation measures must be selected below:

Mitigation Land Options – As described by the U.S. Fish and Wildlife Services’ (USFWS) “Industry Conservation Plan” and the “American Burying Beetle Conservation Strategy For the Establishment, Management, and Operations of Mitigation Lands, May 2014”.

Individual- or Permittee-responsible for mitigation lands: These consist of mitigation lands established by the Permittee (Lessee/Operator). Such mitigation tracts must be described in detail and included in the project descriptions. Such lands must, to the maximum extent practicable, meet the minimum standards and other requirements described in Service guidelines. Also described  in Service  guidelines, conservation easements and agreements must be approved by the Service prior to any habitat impacts that could result in take (negative impacts to the ABB and/or their habitat) of ABBs. The Permittee or their designee is responsible for ensuring the success of and managing the mitigation land in perpetuity, even if the project is finite in duration (refer to Service guidelines).

Conservation Banks: Conservation banks are mitigation lands that are established by a Bank Sponsor. These sites are usually established to mitigation for the effects of multiple projects. By definition a Service-approved conservation bank meets the minimum standards and other requirements described in Service guidelines. Conservation banks are established through a conservation bank agreement with the Service and conservation easements for the bank must be approved by the Service. When a Permittee chooses to mitigate through the purchase of credits in a Service-approved conservation bank, the bank sponsor is responsible for ensuring the success of and managing the mitigation land in perpetuity upon sale of the credits. If a Permittee chooses this option, Permittee must purchase appropriate credits prior to any habitat impacts that could result in take of the ABB.

Third Party mitigation lands: These mitigation lands are usually established for a single project or project proponent rather than multiple projects or proponents as are conservation banks. Such lands and agreements must, to the maximum extent practicable, meet the minimum standards and other requirements described in Services guidelines. Conservation easements and agreements must be approved by the Service prior to any habitat impacts that could result in take of ABB. The mitigation land sponsor (landowner or easement holder)  is responsible for and assumes liability for the success of and management of the approved mitigation land in perpetuity.

ABB Presence/Absence Surveys

ABB Presence/Absence Surveys: In order for the Service to consider a survey valid within the state of Oklahoma, surveys for the ABB must occur during the ABB active season. The Service considers the ABB active season in Oklahoma to begin after five consecutive nights when the minimum nightly temperature reaches 60 degrees Fahrenheit or greater. Surveys completed prior to July 28 are good only for that active season. Surveys completed after July 28, however, will be valid until the start of the new active season, and are valid throughout the dormant season (Fall and Winter).
If a survey was not conducted between July 28 and the end of the active season then the Lessee must wait to conduct the presence/absence survey until the active season starts again in May of the next year. This means that the Environmental Assessment for the drilling of the new well can continue, but the EA and drilling permit cannot be approved by the Osage Agency Superintendent until a negative survey result has been obtained.
These surveys must be conducted by individuals who hold an approved ABB surveyor as determined by the USFWS.  A list of approved surveyors can be found at the following web site:
http://www.fws.gov/southwest/es/oklahoma/documents/abb/abb%20permit%20holders%20last%20updated%2 0mar192014.pdf

I certify that this questionnaire accurately describes the proposed drilling activity. I also acknowledge that my drilling activities are in and will be in compliance with 25 CFR Part 226 as described in this questionnaire and other applicable regulations.

Signed: 		Date 	

BIA Representative:	Date