State Grants Technical Performance Report Template

OMB No.: 1093-0012
Expires: XX/XX/XXX

V4 06/13/2024

OWPO TECHNICAL PERFORMANCE REPORT TEMPLATE

In accordance with the Bipartisan Infrastructure Law (BIL), 2 C.F.R. § 200.329 Monitoring and reporting program performance, and the terms and
conditions of States’ awards, a Technical Performance Report is due on a periodic basis. The report must cover activities that occurred during the
specified period of performance. A State may refer to the Notice of Award for specific due dates.
The Department has determined that providing the information outlined in the following template (including the applicable fields of the attached Data
Reporting Template) meets the Technical Performance Report required.
Instructions: Please attach additional documents/notes and/or photos, if necessary. If more space is needed, please use Section 15 for Additional
Supporting Details. All information provided in this report shall be specific to the respective grant and reporting period. Please refrain from including
information that falls outside of the reporting period of this report.

SECTION 1 – GRANT INFORMATION
Grant Number:

FAOR:

Period of Performance for Grant:

Recipient:

AO:

Period of Performance Covered by this Report:

Project Title or Grant Phase:

Submitted By:

Date of Report:

SECTION 2 – INVENTORY OF ORPHANED WELLS
Indicate separately the current and/or estimated number of documented and undocumented orphaned wells remaining on State and private lands at the
end of the reporting period. Estimate the total number of orphaned wells to be plugged with the respective Grant funding.
Documented Orphaned
Wells Remaining

Estimated Number of
Undocumented Orphaned
Wells

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Estimated Number of
Orphaned Wells to be Plugged

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Have newly documented orphaned wells been identified on State or private lands since the last submittal? If this is the first report
submittal of the respective Grant, have newly documented wells been identified since submittal of the Work Plan?

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If yes, identify the orphaned wells newly documented and the methodologies used to identify such wells.

The total State orphaned well inventory is included in the submittal of this report with precise locations (i.e., latitude and longitude in
decimal degrees). *Not required.

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SECTION 3 – ORPHANED WELLS PLUGGED, REMEDIATED, AND RECLAIMED
Provide the total numbers of wells plugged, remediated, and/or reclaimed during the reporting period with the respective Grant funding.
(e.g., BLANK wells plugged, BLANK wells remediated, BLANK wells reclaimed from the period of DD/MM/YYYY – DD/MM/YYYY)

Acknowledge understanding that the Data Reporting Template must be submitted in addition to this report. The Data
Reporting Template contains a list of wells plugged, remediated, and/or reclaimed, and other well-specific data, such as well
names, well ID’s, well types, precise locations (latitude and longitude in decimal degrees), dates plugged, and other fields, if
applicable. This data shall indicate if an orphaned well was plugged, but the associated well site and surrounding areas were
not remediated or reclaimed. *Please do not include information on wells plugged, reclaimed, and/or remediated with other
Grant funding or wells addressed outside of the reporting period of performance.

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SECTION 4 – PLUGGING AND ABANDONMENT WITNESSING DOCUMENTATION
Acknowledge understanding that Plugging and Abandonment (P&A) witnessing documentation is to be provided to the Department
upon Request. Please note, documentation is not being requested at this time.

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Select

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SECTION 5 – METHANE EMISSIONS REDUCTION AND WATER CONTAMINATION
Provide a brief description of the technology and methodologies used for methane emissions reduction in the current Grant. Indicate how high-methane
emitters were identified and prioritized during the reporting period.

Indicate the total methane emissions reduced as a result of plugging, remediating, and reclaiming during the reporting period, including units of measurement.

Provide any other pertinent information for pre- or post- plugging methane emissions testing and/or reduction during the reporting period.

Provide a brief description of surface water or groundwater contamination identified, and if applicable, the methodologies used to remediate the
contamination during the reporting period.

Acknowledge understanding that a State must inspect each orphaned well site being considered under a grant: 1) To screen
for leaks of methane and other gases, and if identified, to measure the rate of such leaks; and 2) To identify potential surface
water or groundwater contamination.
Acknowledge understanding that a State will conduct or supervise post-plugging inspections within 12 months of the plugging
activity to verify: (1) The lack of gaseous emissions and water contamination from plugged wells; and 2) The achievement of
vegetation performance standards that are appropriate to the site’s future land uses, if applicable.

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Select

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SECTION 6 - JOBS CREATED OR SAVED
Has the estimated number of jobs created or saved through the respective Grant-funded activities changed from the original
application?

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If yes, provide the updated total of jobs created and/or saved through the respective Grant funding.

Provide any other pertinent information on how the respective Grant funding is being used to lower unemployment within the State.

SECTION 7 - HABITAT RESTORATION
Provide the total amount of habitat restored, including units of measurement (acres or feet), during the reporting period.

Acknowledge understanding the Habitat Restoration metric is intended to be a broad metric not limited to only habitat restoration but
also include surface restoration. The State is expected to document the total amount of land (acres or square feet) that was associated
with the well and the well site and has been restored and returned to a condition suitable for other uses. This metric is not intended to
capture disturbance caused by the project itself, such as creating and restoring access roads.

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SECTION 8 – ENVIRONMENTAL JUSTICE
Briefly describe how the State has identified and prioritized well plugging and site reclamation to reduce health or environmental burdens for disadvantaged
communities (including Federally Recognized Tribes and communities identified as disadvantaged using the CEJST), such as through plugging wells and
remediating sites that are within 0.5 miles of a disadvantaged community, during the reporting period.

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Provide any other pertinent information on how the respective Grant phase funding is improving economic conditions in economically distressed areas in the
State, including those areas with Environmental Justice concerns.

SECTION 9 – WORK SCHEDULE
Have there been any changes to the work schedule?

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If yes, indicate the changes in work schedule, reasoning for the changes, and if the objectives for the period of performance will be met.

SECTION 10 – SIGNIFICANT DEVELOPMENTS
Address any problems, delays, or adverse conditions that may materially impair the period of performance or the ability to meet the objective of the award.
Describe the action(s) taken, or contemplated, and any assistance needed to resolve the situation.

Describe any favorable developments that either: 1) Enable quicker achievement of milestones or objectives; or at less cost than anticipated; or 2) Produce
more or different beneficial results than originally anticipated.

Acknowledge understanding that Significant Developments, under 2 CFR 200.329(e), are events that may occur between the scheduled
performance reporting dates that have significant impact upon the supported activity. In such cases, States must inform DOI as soon
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as the development becomes known.

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SECTION 11 – MEDIA RELATIONS
Has respective Grant phase information and relevant reports been posted to a public website and/or dashboard?

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If yes, include the media link(s) for the public website and/or dashboard.

Has the State received, been involved in, or is aware of any media coverage, including publications, press releases, articles, videos, or
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other materials regarding respective Grant phase-funded activities during the reporting period?
If yes, include the media link(s) or attach supporting documentation with the submittal of this report.

Acknowledge understanding that per the respective Grant Guidance and Sec. 40601(c)(4)(B)(i)(III) of the BIL, States applying for the
respective Grant phases are required to post non-sensitive information regarding the activities performed under such Grant to a public Select
website.
SECTION 12 – SUCCESSES
Describe programmatic successes the State has had or is experiencing associated with well plugging, remediation, and restoration funded by the respective
Grant and the administration of the grant during the reporting period, including accomplishments, lessons learned and best practices.

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Describe success stories the State has had or is experiencing associated with well plugging, remediation, and restoration funded by the respective Grant and
the administration of the grant during the reporting period, including positive engagement and/or feedback with landowners.

SECTION 13 - CHALLENGES
Describe challenges the State has had or is experiencing associated with well plugging, remediation, and restoration funded by the respective Grant phase and
the administration of the grant during the reporting period, including negative engagement and/or feedback with landowners.

SECTION 14 – GENERAL FEEDBACK
This is an opportunity for the State to provide the Department with feedback on the Department’s implementation of the respective Grant phase and the
Department’s administration and oversight of the award, including the communication and coordination between the Department and the State.

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SECTION 15 - ADDITIONAL SUPPORTING DETAILS
Section

Topic

Supporting Details

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TECHNICAL PERFORMANCE REPORT CERTIFICATION
Authorized Representative Name:

Digital Signature and Date:

STOP HERE - FOR DOI STAFF ONLY
OWPO REVIEW
FAOR:

Digital Signature and Date:

PM:

Digital Signature and Date:

Notes:

PAPERWORK REDUCTION ACT STATEMENT: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number and expiration date. The OMB control number for this template is 1093-0012 (expiration date: XX/XX/XXXX).
BURDEN ESTIMATE STATEMENT: Public reporting for this form is estimated to average 32 hours per response. Please direct comments regarding the burden estimate or any other aspect of this information
collection to: U.S. Department of the Interior Information Collection Clearance Officer, 1849 C St., N.W., Washington, DC 20240.

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