Reclamation Application Form

PDF Version (160 Kb, 12 Pages)

1. GENERAL INFORMATION

1.1. IOGC Agreement Number (OS-#### or RW-####):

First Nation/Band:
Reserve Name and Number:
Surrender type: Partial___ Full___

1.2. Surface Legal Land Survey Description of Primary Site and Associated Sites included in this Reclamation Application (for associated sites not part of the reclamation application, see section 1.6):

Facility Description(s) (wellsite, access road, battery, sump, riser, pipeline, etc.) ______________________________

Quarter___
Section___
Township___
Range___
Meridian___

Latitude:
Longitude:

1.3. Contact Information

Lessee or Grantee Name:

Contact Name:
Title:
E-mail:
Mailing Address:

Office Phone #: ( )
Cell Phone #: ( )
Fax #: ( )

Environmental Consultant Company Name:

Contact Name:
Title:
E-mail:
Mailing Address:

Office Phone #: ( )
Cell Phone #: ( )
Fax #: ( )

First Nation Name:

Contact Name:
Title:
E-mail:
Mailing Address:

Office Phone #: ( )
Cell Phone #: ( )
Fax #: ( )

1.4. Provincial/Territorial Information

Province/Territory:
Unique well/facility identifier(s):_____________________________ or ___Not Applicable
Licence numbers(s):_____________________________ or ___Not Applicable
Total area of land to be surrendered/reclaimed (in hectares):

1.5. Agreement/Activity Type (check all that apply):

___No Surface Disturbance (surveyed only)Footnote 1
___Drilled and Abandoned (D&A) WellsiteFootnote 2
___Wellsite: Oil___ Gas___ Sweet___ Sour___ Disposal___
___Battery
___Riser
___Borrow Site
___Access Road: year round___ seasonal___ temporary___
___Prepared Wellsite (not drilled)
___Compressor
___Pipeline
___Remote Sump
___Other (describe):

1.5.1. Well or pipeline abandonment date(s):

1.6. Associated Facilities and Infrastructure

Does the Primary Site have any of the following associated facilities or infrastructure not part of this Reclamation Application?

Facility Description (wellsite, access road, battery, sump, pipeline) Yes No IOGC OS-####
or
RW-####		 Status (active, undergoing reclamation, abandoned, surrendered) Quarter Section Township Range Meridian
Note: This section assists IOGC track the status of associated facilities and infrastructure.
Wellsite(s)                  
Flowline(s)/
Pipeline(s)		                  
Battery                  
Compressor                  
Year-round Access Road                  
Temporary Access Road                  
Seasonal Access Road                  
Remote Sump                  
Riser                  
Borrow Site                  
Log Deck/Storage                  
Campsite                  
Other (describe):                  

1.7. Reclamation Criteria Selected

___Alberta’s 2010 Reclamation Criteria for Wellsites and Associated Facilities
___Access road portion of Alberta’s 2010 Reclamation Criteria for Wellsites and Associated Facilities
___Alberta’s Reclamation Assessment Criteria for Pipelines – 2001 Draft
___Other (describe):

1.8. Reclamation Criteria Land Category

___Cultivated
Construction Date:
___Peatlands
Construction Date:
___Native Grasslands
 
 
Constructed Before January 1, 1993
Site Abandoned and/or Reclaimed DateFootnote 3:
 
 
Constructed from January 1, 1993 to April 30, 1994
Site Abandoned and/or Reclaimed DateFootnote 3:
 
 
Constructed On or After April 30, 1994
Site Abandoned and/or Reclaimed DateFootnote 3:
 
___Forested Lands
 
 
Constructed Before January April 30, 1994
Site Abandoned and/or Reclaimed DateFootnote 3:
 
 
Constructed from January April 30, 1994 to June 1, 2007
Site Abandoned and/or Reclaimed DateFootnote 3:
 
 
Constructed On or After June 1, 2007
Site Abandoned and/or Reclaimed DateFootnote 3:
 

1.8.1. Have the criteria used to assess the site been changed or defaulted to another?

___Yes ___No
If Yes, indicate the new criteria category and attach documentation in Schedule One (Section 8) showing acceptance through a written prior approval by IOGC and a First Nation Band Council Resolution (BCR).

2. ADDITIONAL SITE INFORMATION

2.1. Partial Surrender/Memorandum of Partial Surrender (MoPS)

Notes:

  • For a MoPS to be processed, IOGC requires an amending agreement to be submitted for the portion that will be excluded from the partial surrender.
  • The MoPS and the amending agreement will be executed simultaneously.
  • See pages 11 and 12 for Guide to Completing an IOGC Memorandum of Partial Surrender (MoPS)

2.1.1. Is the application for a partial surrender (MoPS)?

___Yes ___No
If yes,

  1. provide rationale for a partial and not full surrender:
  2. has an amending agreement been submitted to IOGC? ___Yes ___No
    If No, the reclamation application and MoPS will be not be processed until the amending agreement is received.

2.2. Land Use

2.2.1. What is the current surrounding land use?

___Agricultural
___Commercial
___Industrial
___Residential/Parkland
___Other:

2.2.2. Has the end land use for the site changed?

___Yes ___No
If yes,

  1. indicate previous land use:
    ___Agricultural
    ___Commercial
    ___Industrial
    ___Residential/Parkland
    ___Other:
  2. was the proposed end land use discussed with the First Nation and IOGC and is the criteria consistent with those discussions? ___Yes ___No
    For either answer, include Land Use Criteria Change AuthorizationFootnote 4 with written authorization from IOGC and BCR from First Nation.

2.3. Non-Oilfield Waste

2.3.1. Is there any non-oilfield waste buried on site (e.g., concrete, gravel, debris)?

___Unknown
___No
___Yes
If Yes, provide details, First Nation BCR approval, and confirm location(s) identified on attached survey plan or map:

2.4. Facilities or Features to Remain in Place

2.4.1. Are there any facilities or features (e.g., water well, access road, Texas gate, approaches, culverts, fences, others) to remain in place?

___Yes ___No
If yes,

  1. describe what feature(s) are to remain and their purpose:
  2. are the facilities or features stable and non-hazardous? ___Yes ___No
    If No, describe:
  3. has a First Nation BCR been securedFootnote 5? ___Yes ___No
    If Yes, is the BCR and copy of the existing survey plan outlining which facilities are to remain in place attached? ___Yes ___No
    If No, the application will be deemed incomplete until the BCR is received.

2.5. Surface Land Information

2.5.1 Was the surface agreement granted on or after 1977?

___Yes ___No
If yes, provide the approved Canadian Land Survey Registry (CLSR) Plan #Footnote 6:

3. ENVIRONMENTAL SITE ASSESSMENT AND CONTAMINATION INFORMATION

Notes:

3.1. Environmental Site Assessment (ESA) Work Completed – check off all appropriate sections

___Phase 1 ESA not completed as wellsite was prepared, but not drilled or the site was surveyed only.
___The Phase 1 ESA showed no contamination was likely present, so no Phase 2 ESA or remediation was completed.
___The Phase 1 ESA showed contamination was likely present so a Phase 2 ESA was completed.
___The Phase 1 ESA showed insufficient information to determine if contamination was likely present, so a Phase 2 ESA was completed.
___The Phase 1 ESA showed contamination was likely present so remediation was completed in consultation with IOGC and the First Nation.
___The Phase 2 ESA showed contamination was not present or was within acceptable valuesFootnote 7.
___The Phase 2 ESA showed contamination was present so remediation was completed in consultation with IOGC and First Nation.
___Site was known to be contaminated so remediation was completed in consultation with IOGC and First Nation, and a Phase 1 ESA completed.

3.1.1. Remediation Activities and Confirmatory Sampling

3.1.1.1. Were remediation activities ever undertaken?

___Yes ___No (go to 4)
If Yes, was confirmatory testing/sampling undertaken following remediation? ___Yes ___No
If No, provide details:
If Yes,

  1. are report(s) attached? ___Yes ___No
  2. were the Canadian Environmental Quality Guidelines of the Canadian Council of Ministers of the Environment (CCME)Footnote 8 used? ___Yes ___No
  3. Were any other guidelines used in the absence of CCME guidelines? ___Yes ___No
    If Yes, list guideline(s) and parameter(s) used:
  4. Is there any remaining contamination above CCME Guidelines? ___Yes ___No
    If Yes, this will be deemed a non-routine application and will warrant additional information.
3.1.1.2. Identify contamination type(s):

___Hydrocarbons
___Metals
___Salts
___Pesticides/Sterilants
___Other:

4. ROUTINE vs. NON-ROUTINE APPLICATIONS

Notes:

___Yes ___No - A. If standard criteria were unable to be met, was professional judgment used to provide justification to explain a "pass"?

___Yes ___No If Yes, and justifications were used were they discussed with an IOGC Environmental Representative?
If Yes, provide Environmental Analyst’s Name:
Date of discussion:
Summary of discussion (describe or attach email/correspondence):
If No, the application will be deemed incomplete.

___Yes ___No If Yes, and justifications were used were they discussed with the First Nation?
If Yes, provide First Nation Representative’s Name:
Date of discussion:
Summary of discussion (describe or attach email/correspondence):
If No, the application will be deemed incomplete.

___Yes ___No - B. Is there any remaining contamination above CCME Guidelines?

___Yes ___No - C. Has a Memorandum of Surrender or reclamation certificate for this site been executed and then cancelled?
If Yes, provide additional detail:

___Yes ___No - D. Should this be considered a non-routine application for any other reason not listed above?
If Yes, provide additional detail:

5. PROFFESSIONAL ASSURANCE

Professional members who signed off on the reclamation and/or remediation assessments.

Assessment Date Company Professional’s Name *Professional Designation(s) and Registration No(s).
*A professional is identified as an individual who possesses a post-secondary degree or a technical diploma in biological, environmental or natural resources science from an accredited college or university, or equivalencies; has technical knowledge and experience in the assessment of vegetation, wildlife, soils and/or hydrology; and is acting within his/her area of expertise.
Phase 1 ESA:        
Drilling Waste Disposal/ Compliance Option(s):        
Phase 2 ESA – Site Investigation:        
Remediation and Confirmatory Results:        
Landscape Assessment:        
Vegetation Assessment:        
Soil Assessment:        
Other:        

Work should be completed by an assessor who is a registered member in good standing of a regulated professional association constituted under an act of the provincial Legislature or the assessor’s work is reviewed by a member of a regulated professional association.

6. LESSEE/GRANTEE/SURFACE CONTRACT HOLDER DECLARATION

The Declaration must be signed by the Lessee/Grantee/Surface Contract Holder (consultant signatures are NOT acceptable).

I, _____________________________
(Print Name)
of ____________________________________ declare that,
(Lessee/Grantee/Surface Contract Holder)

This application was prepared and completed under my direction. Based on my inquiries of the person or persons who managed the application components required to complete this application the information is, to the best of my knowledge and belief, true, accurate and complete. The following tasks have been completedFootnote 9:

I understand that incomplete applications will not be accepted and we will have to reapply once the missing information has been added. I also declare that, to the best of my knowledge, all of the information contained within this Application is accurate and includes a complete representation of all the information that is required to be submitted in this IOGC Reclamation Application. I am aware that it is an offense to provide false or misleading information.

_____________________________
Name (Print)
_____________________________
Signature
_____________________________
Position
_____________________________
Date

7. APPLICATION SUBMISSION – Indian Oil and Gas Canada

A complete application package must be submitted and include the following, in order:

___Cover letter

___IOGC Surrender and Reclamation Application Form

___Band Council Resolution for any facilities/structures to remain in place

___Schedule One (Attachments) as per IOGC’s Reclamation and Surrender Application Form

___Schedules Two to FiveFootnote 11 (including all checklists and attachments) as per Alberta’s 2010 Wellsite Reclamation Certification Application Form 2010 Reclamation Criteria for Wellsites and Associated Facilities.

Forward one unbound hard copy of the complete application and one digital version (PDF Format on CD) to the First Nation and:

Indian Oil and Gas Canada
Attn: Environment Unit
Suite 100, 9911 Chiila Blvd
Tsuu T’ina, AB T2W 6H6

Submission Considerations:

8. SCHEDULE ONE - Attachments

Check off appropriate boxes indicating which documents are included in the Schedule.

Included? Not Applicable Item
___ ___ A. Approved Survey Plan
  • Area to be surrendered outlined in yellow.
  • Survey plan must cover one quarter section.
  • Details on the plan (or in the Detailed Site Assessment Report) must be sufficient to show the relationship of the site to the immediately surrounding area and the following (where applicable):
    • surface drainage, slope and direction;
    • land use;
    • uncleared areas (bush);
    • distance from wetlands/waterbodies and sensitive areas;
    • roads and/or trails;
    • buildings;
    • fence lines; and
    • any facilities or improvements to remain in place.
  • Survey plans must be readable, and include site dimensions, distances and bearings.
___ ___ B. For a Memorandum of Partial Surrender, include a survey plan outlining lands to remain in place
___ ___ C. Criteria Change Authorization (section 1.8.1) including written authorization from IOGC and First Nation BCR
Alberta’s 2010 Reclamation Criteria for Wellsites and Associated Facilities (AENV 2010) provides for justification when the reclamation criteria for the appropriate end land use cannot be achieved due to site-specific conditions.
___ ___ D. Land Use Criteria Change Documentation (section 2.2) from IOGC and First Nation BCR (e.g. from forested to cultivated)
    E. Non-oilfield waste burial Documentation from IOGC and First Nation (section 3)
    F. First Nation Band Council Resolution (BCR) to leave facilities in place and survey plan outlining facilities/improvements to remain (section 2.4.1)
___ ___ G. Documentation of discussions with IOGC and the First Nation for a site that does not meet standard criteria (section 4(A) non-routine application)
___ ___ H. Remediation documentation and/or reports
    Next steps: Four (4) executed originals of the Memorandum of Surrender (MOS) or Memorandum of Partial Surrender (MoPS) are to be submitted to IOGC following joint First Nation-IOGC-Lessee/Grantee reclamation inspection.

Guide to Completing an IOGC Memorandum of Surrender (MOS) or Memorandum of Partial Surrender (MoPS)

  1. Go to Indian Oil and Gas Canada.
  2. On the right-hand side, click on 'Doing Business’, then 'Forms’, then 'Memorandum of Surrender (MOS)’ or 'Memorandum of Partial Surrender (MoPS).’
  3. Download the Word Version.
  4. Follow instructions 4a to 4f in the text boxes below.
  5. Make FOUR (4) original copies of the MOS or MoPS.
  6. If Corporate Seal is not affixed, IOGC requires that the signature be witnessed by at least one person who is not a party to the Contract, and Affidavit of Witness (attached as a following page) completed before a Notary Public or Commissioner of Oaths holding a valid appointment for the Province within which the Reserve lands are located.
    Note: If executed by Power of Attorney, Lessee/Grantee original Power of Attorney documentation is required to be forwarded to IOGC, if not previously provided (see Indian Oil and Gas Canada for form).
  7. Submit FOUR (4) original copies MOS or MoPS and Affidavit of Witness documentation, if required, to IOGC.

Notes:

INDIAN OIL AND GAS CANADA

(Section 44 – Indian Oil and Gas Regulations, 1995)

MEMORANDUM OF SURRENDER OR MEMORANDUM OF PARTIAL SURRENDER

TO THE GOVERNMENT OF CANADA IN THE MATTER OF Surface Agreement No. [OS-___Footnote 12, TS-___, FS-___, RW-___, TW-___ or FW-___ ] dated [DateFootnote 13 __________] ("Contract") overing the lands therein described.

The undersigned, as [Lessee or GranteeFootnote 14 ___], in the said Contract, hereby for good and sufficient consideration, unconditionally releases, surrenders and quitclaims unto the Government of Canada, its entire right, title, estate in the Contract.

IN WITNESS WHEREOF [Corporate NameFootnote 15 __________________________] has caused these presents to be executed, this ___ day of __________Footnote 16 201__.

[CORPORATE NAMEFootnote 17 __________________________]

__________________________

Witness

The section below will be filled in by Indian Oil and Gas Canada

This surrender is effective as of the ___ day of __________ 201__ ("Effective Date").

APPROVED AS OF THE EFFECTIVE DATE:

AFFIDAVIT OF WITNESS
Re: Execution (Signing) of Document

Canada Province of __________________
I _________________________________
of the City of _______________________
of the Province of ___________________
to Wit
Make Oath and Say

  1. That I was personally present and did see the attached instrument duly executed by ____________________________________________________.
  2. That I know the said party(ies), and that the said party(ies) in my belief is/are the full age of majority for the Province of __________________________.
  3. That I am the subscribing witness to the said instrument.

Signature of Witness __________________________.

SWORN before me at the City of __________________, Province of __________________, this ___ day of __________________, _______.

A Notary Public, or a Commissioner for taking Oaths, in and for the Province of __________________.

My commission expires: ___________.

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