Environmental Assessment Questionnaire

OMB# 1076-0180

Expires XX-XXXX

U.S. Dept. of the Interior Bureau of Indian Affairs Osage Agency

Revised 01 APR 2016

APPLICATION FOR PERMIT TO DRILL ENVIRONMENTAL ASSESSMENT QUESTIONNAIRE

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.

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):

1. 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

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.

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

3. 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.

4. 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:

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

2. Estimated setting depths of casing.

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

4. 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:

1. 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).

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

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

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

5. 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.

6. 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?

7. 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.

8. 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?

9. 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.

8. National Historic Preservation Act

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

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

3. 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

1. 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”.

ABB Presence/Absence Surveys

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

Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to comply with the requirements of the National Environmental Policy Act of 1969 (NEPA) by evaluating the potential impacts resulting from the proposed action. Your response is voluntary and we will not share the results publicly. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB Control Number. OMB has reviewed and approved this survey and assigned OMB Control Number 1076-0180, which expires ##/##/####.

Estimated Burden Statement: We estimate the form will take you 24 hours to complete, including time to read instructions, gather information, and complete and submit the form. You may submit comments on any aspect of this information collection to the Information Collection Clearance Officer, Office of Regulatory Affairs & Collaborative Action—Indian Affairs (RACA), U.S. Department of the Interior, 1001 Indian School Road NW, Suite 229, Albuquerque, NM 87104.

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