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BLM Form 3150-5

FS Form 2800-16a

(November 2018)

UNITED STATES

DEPARTMENT OF THE INTERIOR

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, 2021

NOI Case File No.

Project Name

Lessee or Operator

Geophysical Co.

Address

City

State

City

State

Zip Code Phone No.

(Include area code)

Zip Code Phone No.

(Include area code)

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

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, 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)

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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 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)

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