BLM Form 3150-5 / Notice of Completion of Geophysical Exploration Operatio

BLM Form 3150-5 UNITED STATES FS Form 2800-16a DEPARTMENT OF THE INTERIOR (May 2015) BUREAU OF LAND MANAGEMENT DEPARTMENT OF AGRICULTURE FOREST SERVICE NOTICE OF COMPLETION OF GEOPHYSICAL EXPLORATION OPERATIONS					FORM APPROVED OMB NO. 1004-0162 Expires: October 31, 2018
					NOI Case File No.
					Project Name
Lessee or Operator			Geophysical Co.
Address			Address
City		State	City		State
Zip Code	Phone No. (Include area code)		Zip Code	Phone No. (Include area code)
Email Address			Email Address

1. If different from the Notice of Intent and Authorization to Conduct Geophysical Exploration Operations (NOI), show the lands, line locations, source points, and routes that you actually used for geophysical activities. To depict any deviations from what you had proposed in the approved NOI, we recommend a PDF version of a 7 1/2-minute USGS quadrangle or the USGS map scale commonly used in the area along with 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 planned in the NOI and any deviations from the NOI in the actual access routes to and within the project area, source and receiver point locations and lines, and source point locations used in your geophysical operations. Maps and data must also include surface ownership, Federal minerals, and any Federal lands under lease. Explain reasons for deviations from the original NOI.

2. Miles of source line or acres of survey on: a. Your Lease b. Other Federal lands

3. Describe how you plugged any shot holes.

4. If the Bureau of Land Management (BLM) or the Forest Service (FS) requests it, attach a copy of the “Hole Plugging Log” describing each shot hole, including whether holes were wet or dry, the static water level, flowing holes, breached or caved holes, or lost hole locations.

5. Describe any surface disturbance, disturbance locations, and how you reclaimed it.

I CERTIFY that the oil and gas explorations approved under the NOI were completed on

complied with all terms and conditions of the approved NOI. (Date)

and that the operations

Printed Name of Authorized Company Representative Signature of Authorized Company Representative

Title of Authorized Company Representative Date

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)

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 determine when exploration operations are completed and to determine that mitigating measures are performed to protect the environment.

ROUTINE USES: This information may be disclosed to agencies, organizations 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 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 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 estimated to average 20 minutes 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 3150-5 and FS Form 2800-16a, page 2)