b. Other Federal lands
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BLM Form 3150-5
FS Form 2800-16a
(November 2018)
OMB NO. 1004-0162
Expires: October 31, 2021
NOI Case File No.
Project Name
Lessee or Operator
Geophysical Co.
Zip Code Phone No.
(Include area code)
Zip Code Phone No.
(Include area code)
Email Address
Email Address
1. If dierent 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 le 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
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, owing 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 and that the operations
complied with all terms and conditions of the approved NOI. (Date)
Printed Name of Authorized Company Representative
Signature of Authorized Company Representative
Title of Authorized Company Representative
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 3150-5 and FS Form 2800-16a)
click to sign
click to edit
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 benet.
BLM/FS will use this information to process geophysical exploration notices.
Response to this request is required to obtain 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 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 Ocer, Washington, D. C. 20240.
(BLM Form 3150-5 and FS Form 2800-16a, page 2)