BLM Form 3150-4 / Notice of Intent and Authorization to Conduct Geophysica

BLM Form 3150-4 UNITED STATES FS Form 2800-16 DEPARTMENT OF THE INTERIOR (May 2015) BUREAU OF LAND MANAGEMENT DEPARTMENT OF AGRICULTURE FOREST SERVICE NOTICE OF INTENT AND AUTHORIZATION TO CONDUCT GEOPHYSICAL EXPLORATION OPERATIONS					FORM APPROVED OMB NO. 1004-0162 Expires: October 31, 2018
					NOI Case File No.
					Project Name
Lessee or Operator			Geophysical Exploration Bond Holder
Lessee or Operator Contact
Address
City		State	Which Agency holds the bond? BLM Forest Service
Zip Code	Phone No. (Include area code)		Bond No.	Bond Amount: $

Email Address

Geophysical Co.			Geophysical Exploration Project Representative
Address			Address
City		State	City		State
Zip Code	Phone No. (Include area code)		Zip Code	Phone No. (Include area code)
Email Address			Representative’s Email Address

Party Chief/Field Operations Point of Contact (POC)

POC Field Operations Cell Phone No. (Include area code) Email Address

A separate Plan of Operations is attached addressing items 1 – 5 below. Yes No.

1. Location Description and Maps: Give the general land description of the lands involved, limited to Meridian, Township, Range, and Section(s) or metes and bounds as appropriate. You must also submit an electronic map (in PDF) with a minimum scale of one-half inch per mile showing the general area and project location. We recommend a PDF version of a 7 1/2-minute USGS quadrangle or the scale commonly used in the area. In addition, you must submit 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). Maps and GIS data must include clearly attributed locations of operations and facilities, including staging areas, access routes to and within the project area, source and receiver point locations and lines, shot point locations, surface ownership, Federal minerals, and any Federal lands under lease. You must identify separately the number of Federal surface (by agency), state surface, fee surface, and other surface acres within the project area, and the estimated acreage of surface disturbance.

2. Do you hold any Federal leases within the project area? Yes No (If yes, indicate location and lease numbers on an attached map.) There is no fee for operations conducted on your Federal lease (outside of Alaska).

3. If you are proposing seismic exploration, how many miles of source line (2-D), or acres (3-D) (to the nearest 10 acres) of survey are on:

1. Your Federal Lease b. Other Federal lands

4. When do you expect to start exploration?

How long will the project last?

days.

Describe any of your critical timeframes associated with the proposed project, such as equipment or contractor availability.

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.

(Continued on page 2)

5. Description and Type of Operations (check all that apply);

1. Survey Type: 2-D 3-D Gravity/Magnetic Other (explain):

Additional information on the survey type:

2. Survey Method: Shot hole Vibroseis Other (explain):

For shot holes:

What type and amount of explosives per source will you use? What shot point pattern and spacing will you use?

What will be the shot hole depth?

What type of receivers (wired/wireless) will you use and how will they be transported and placed?

What will be the receiver and source spacing (in feet) and spacing between the source and receiver (in feet)? Additional information on the survey method:

3. Seismic Source and Transport Methods: Vibroseis Trucks Pick-up Truck Drill Buggy ATV/UTV Helicopter Backpack

Describe your seismic source and transportation plans, including types of vehicles, numbers of vehicles for each aspect of the project, routes, and methods you will use to access the project area:

4. Operating Procedures: Describe your operating procedures, including how you will minimize surface impacts and ensure compliance with the Terms and Conditions of this NOI. Describe staging areas and support facilities you need, such as helispots, temporary camps, equipment storage; fuel storage; powder magazines; construction of roads or trails; proposed plugging procedures for shot holes; waste management and spill prevention; reclamation; and general clean-up procedures.

(Continued on page 3) (BLM Form 3150-4 and FS Form 2800-16, page 2)

Terms and Conditions

1. The Bureau of Land Management (BLM) or Forest Service (FS) (Agency) must approve any Surface disturbing activities in addition to those approved in the NOI, such as route changes, placement of magazines, towing with a tractor, blading, dozing, snow removal, and vegetation removal. I must notify the Agency in writing of any changes in the original proposal and have Agency approval in writing for the changes before proceeding with them. Stacking source points to avoid sensitive resources or areas does not require prior Agency approval.

2. This NOI expires on , unless the Agency extends it in writing before that date.

3. I understand that this NOI does not grant any exclusive right to the described lands for geophysical exploration, or other purposes. The land area described above is at all times subject to any other lawful uses by the United States, its lessees, permittees, licensees, and assigns.

4. I must notify the Agency at least days, but no more than

days, prior to initiating the project and entering upon lands managed by the Agency.

5. In the field, each seismic crew must have a copy of the approved NOI and its terms and conditions.

6. The Agency may suspend or terminate this NOI if there is a violation of any of its conditions.

7. I must suspend operations when the operations may unnecessarily damage the surface, such as when rutting would occur due to wet soil conditions.

8. I must indemnify the United States for any liability for damage to life or property resulting from the occupancy or use of public lands under the NOI.

9. I must take all reasonable precautions to prevent and suppress fires. The Agency may specify in writing the fire prevention and firefighting equipment I need. At my expense, I must extinguish all fires set or caused as a result of operations under this NOI and must report all fires to the Agency.

10. I must diligently protect from unnecessary damage United States land and property covered by this NOI. I must pay the United States for any damage resulting from my or my agents’ or employees’ violation of the terms of this NOI or any law or regulation applicable to the lands involved.

11. I must store and handle powder magazines and explosives according to the U. S. Bureau of Alcohol, Tobacco and Firearms standards (see 27 CFR Part 555). I must properly secure loaded shot holes.

12. I must complete shot hole plugging under Agency guidelines and the guidelines of any other local, Federal, or State regulatory authority.

13. I must remove all materials and equipment I placed on the premises and restore the site to the Agency’s satisfaction immediately after I complete the project unless the Agency approves other arrangements.

14. I must file a Notice of Completion (NOC) Form 3150-5/2800-16a within 30 days after completing operations and reclamation. If the location of the project is different from that in the approved NOI, I must submit a revised map with the NOC (1:24,000 scale, where available), including source points.

15. I must pay to the United States $__________________________per __________________________according to the regulations.

16. This geophysical exploration project is subject to the attached Conditions of Approval ________________________ through ____________________and Exhibits _______________._________

WARNING: If you purposely give false or misleading information, you may be fined $10,000, sent to prison, or both (see Title 18 U.S.C. 1001 statement on page 1).

I agree that I and my agents must conduct the geophysical exploration under all Federal, State, local laws, and applicable regulations, and I and my agents must comply with this NOI and any attached terms and conditions.

Printed Name of Authorized Company Representative Signature of Authorized Company Representative Date

Printed Name of Agency Signing Officer Signature of Agency Signing Officer Title of Agency Signing Officer Date

NOTICES

AUTHORITY: This information is solicited under the authority of 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). 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 and 251.

PURPOSE: The primary purpose for collecting this information is to facilitate the timely processing of your notice and inform you of the terms and conditions under which geophysical exploration operations may be conducted.

ROUTINE USES: This information may be disclosed to agencies, organization or persons for authorized purposes as follows: (1) Documentation for public information in support of notations made on land status, records for the management, and use of public lands and resource. (2) Information from the record and/or the record will be transferred to appropriate Federal, State, local or foreign agencies, when relevant to civil, criminal or regulatory investigations or prosecutions. Additional information on authorized routine uses may be found in the published system of records notice, BLM-3, Mineral Lease Management—Interior, which may be viewed at https://www.doi.gov/privacy/blm_notices

DISCLOSURE: Furnishing the information on this form is voluntary, however, failure to submit all or part of the requested information or to complete this form may result in delay or result in revocation of your right to conduct geophysical exploration operations.

The Paperwork Reduction Act of 1995 requires us to inform you that:

The BLM/FS will use this information to process geophysical exploration notices.

Response to this request is required to obtain or retain a benefit.

The BLM/FS would like you to know that 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 1 hour 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 3150-4 and FS Form 2800-16, page 3)