Tribal Implementation Grants - Performance Reporting Template

OMB No.1093-0012

Expires: XX/XX/XXXX

U.S. Department of the Interior

Financial Assistance

Tribal Orphaned Wells Program

Performance Report NarrAtive:

Implementation GRANT

(Optional Template)

Tribes may use this optional template in fulfillment the Performance (Technical) Reporting requirement found in the Notice of Award for the Tribal Implementation Grant. Mandatory elements of the required Performance Report Narrative are described in Section 17 of Notice of Award (NOA) and listed below, in the body of this document.

Tribe:
Prepared by:
Submitted by:
Award Number
Performance Period (MM/DD/YY to MM/DD/YY)

BACKGROUND

(Optional) Provide a brief introductory or background statement about the Tribe, oil & gas activities, and any other relevant information that is not included under specific reporting elements below.

A: Total known and inventoried orphaned wells on tribal land:

B: Total number of orphaned wells plugged, remediated, and reclaimed.

C: Total methane emissions reduced as a result of plugging, remediating, and reclaiming orphaned wells (including a description of the methodologies used for this parameter).

D: Total acres of habitat restored.

E: Total number of jobs created or saved through the funded activities.

F: Plugging and Abandonment (P&A) witnessing documentation for each plugged well.

G: Completed established goals, work in progress, and percentage of work completed.

(See Section 7 “Federal Award Performance Goals” in Notice of Award)

H: Explanation of why established goals and objectives were not met or problems that may

impact the ability to complete work on time with recommendations for resolution, if

appropriate.

(See Section 7 “Federal Award Performance Goals” in Notice of Award)

I: Summary forecast of future activities and how they will be accomplished.

J: Additional pertinent information including, when appropriate, analysis and explanation

of cost overruns or high unit costs.

In addition to narrative summary reports, the Recipient must track and report the data outlined below for all actions taken under this award. The Recipient shall provide the required data to DOI in a format compatible with the suggested reporting template for entry into a centralized database. Suggested performance reporting template is included in the link below. The following data elements are required for each well in the inventory and assessment:

tribal-grant-program-data-reporting-template-optional-oct-2023.xlsx (live.com)

1. Well identification number (ID).

2. Well ID source (e.g., API).

3. Well name.

4. Well type: oil or gas.

5. Latitude/longitude.

6. Location accuracy: estimated or verified.

7. Pre-plugging methane emission measurement or estimate (grams/hr).

8. Methane measurement method.

9. Post-plugging methane emission measurement or estimate (grams/hr).

10. Habitat restored (acres).

11. Habitat restoration date of completion.

12. Surface water contamination present: yes or no.

13. Surface water contamination remediated: yes or no.

14. Surface water remediation date of completion.

15. Groundwater contamination present: yes or no.

16. Groundwater contamination remediated: yes or no.

17. Groundwater remediation date of completion.

18. Population living within 1/2 mile of well.

19. Actual total cost per well of plugging and/or surface reclamation (dollars).

20. Well status: unplugged, plugged, or plugged & abandoned (fully remediated).

21. Witness name and certification.

22. Witness date.

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 10 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.