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FORM APPROVED: DEPARTMENT OF AGRICULTURE DEPARTMENT OF THE (Bureau of Land Management - Main Domain)

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BLM Form 3150-4
FS Form 2800-16
(November 2018)
UNITED STATES
DEPARTMENT OF THE INTERIOR
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, 2021
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/Project 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 le 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. Y
ou 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:
a. Your Federal Lease b. Other Federal lands
How long will the project last? days.
4. When do you expect to start exploration?
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, ctitious, or fraudulent statements or representations as to any matter within its jurisdiction.
(Continued on page 2) (BLM Form 3150-4 and FS Form 2800-16)
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5. Description and Type of Operations (check all that apply);
a. Survey Type: 2-D 3-D Gravity/Magnetic Other (explain):
Additional information on the survey type:
b. SurveyMethod: 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:
c. 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:
d. Operating Procedures: Describe your operating procedures, including how you will minimize surface impacts and ensure compliance with the Terms and Condi-
tions 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 eld, 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 res.
The Agency may specify in writing the re prevention and reghting
equipment I need. At my expense, I must extinguish all res set or
caused as a result of operations under this NOI and must report all
res 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 le 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 dierent 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 ned $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 Ocer
Signature of Agency Signing Ocer
Title of Agency Signing Ocer
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 benet.
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 Ocer,
Washington, D. C. 20240.
(BLM Form 3150-4 and FS Form 2800-16, page 3)
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FORM APPROVED: DEPARTMENT OF AGRICULTURE DEPARTMENT OF THE (Bureau of Land Management - Main Domain)

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Completed 19 July 2020

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