Environmental Review Form

Word Version (332 Kb, 14 Pages)

Section A. Project Identification

  1. Applicant name:__________________________
  2. Project name:__________________________
  3. New project or amendment or change to an existing agreement? ___New project
    ___Amendment (additional well/pipeline, change of use and/or expiry of Environmental Protection Terms)

    If amendment, provide IOGC surface agreement # and go to Section F:_______________
  4. Project location
    1. Legal land description:____________________________________________________
    2. Latitude and Longitude:____________________________________________________
    3. Reserve name and number:____________________________________________________
  5. Anticipated start date or quarter:_______________
  6. Date(s) of site visit(s):_______________
  7. Type of application (See Section C): ___Standard application
    ___Non-standard application

Section B. Project Description

  1. Project Type:__________________________
    1. Surface lease

      ___Developmental well
      ___Exploratory well
      ___Multi-well pad ( # of wells:_________)
      ___Access road
      ___Single well battery
      ___Battery
      ___Disposal well
      ___Remote sump
      ___Pipeline riser
      ___Compressor
      ___Borrow pit
      ___Enhanced Oil Recovery (EOR)*
      ___Steam Assisted Gravity Drainage (SAG-D)*
      ___Coalbed methane*
      ___Other (describe)*:__________________________

      *Contact a Representative from the Environment Unit to discuss how to
      Total size (ha):_________
      Lease width and length (m):_________
      Access road length (m):_________
      Access road width (m):_________
      Camp (ha):_________
      Temporary work space size and use (ha):_________
      Describe purpose:_________

      ___Single well program
      ___Multi-well program

      If "Multi-well program", how many wells are expected to be drilled on reserve by the Applicant within the next year?_________
      Approximately how many wells have been drilled by the Applicant in the last 2 years?_________
    2. Right of way

      ___Pipeline
      Total size (ha):_________
      Length (m) x width (m):_________
      Outside diameter (mm):_________
    3. Exploratory

      ___2D Seismic
      ___3D Seismic
      ___Other:__________________________

      Energy source:__________________________
      Energy size:__________________________
      Line widths (source and receiver if 3D) (m): __________________________
      Spacing, if 3D (m):__________________________
      Total length (km):__________________________
      Total program area:__________________________
    4. Other

      Describe:






    5. Have actions been taken to integrate the project with other existing or planned activities and resources to minimize impacts (i.e. common corridors, parallel or use of existing clearings or rights-of-way)? ___Yes ___No

      Describe:







    6. Provide rationale for the project including how it was located to avoid surrounding environmental constraints.

      Describe:
  2. Product:

    ___Oil
    ___Gas
    ___Sweet
    ___Sour (_______ % H2S)
    ___Produced water
    ___Other (describe):
  3. Describe all proposed project activities including duration (surveying to final reclamation):

    Attach as Appendix 1 as per format described in Guide.
  4. Describe all potential impacts, mitigation, and related residual effects:

    Attach as Appendix 2 as per format described in Guide.
  5. Drilling and Completion Fluids
    1. Drilling fluid:

      ___Not applicable (N/A)
      ___Gel chem
      ___Invert
      ___KCl
      ___Other:
    2. Drilling waste disposal (check all that apply):

      ___Not applicable
      ___Off-reserve
      ___On-reserve
      ___Tanks
      ___Land spray while drilling
      ___Landspray
      ___Land spreading
      ___Pump-off
      ___Approved disposal facility
      ___Mix-bury-cover (on-site)
      ___Mix-bury-cover (remote sump) location:
      ___Other (describe):






    3. Hydraulic fracturing

      ___N/A
      ___Applicable
      1. Number of stages:__________________________
      2. Estimated total fluid/sand volume of each stage:__________________________
      3. Describe how the frac fluid will be handled and stored to prevent contamination:__________________________
      4. What is vertical distance between the deepest water well and the depth of the fractured zone?__________________________
  6. Water source (wells and pipelines):

    ___Not applicable
    ___Off-reserve
    ___On-reserve. If on-reserve, provide location, water type (surface or groundwater), and confirm appropriate authorizations have been secured:

    Estimated water volume required:




    Describe water disposal methods:




  7. Distance to nearest improvements (m):

    Improvement Type:__________________________
    Direction:__________________________
    Distance:__________________________

    Improvement Type:__________________________
    Direction:__________________________
    Distance:__________________________

    Improvement Type:__________________________
    Direction:__________________________
    Distance:__________________________

Section C. Standard vs. Non-Standard Application

Notes:

  1. Are any variances for setback, timing, or environmental requirements as per Section 7 of the Guide required? ___Yes ___No
  2. Will the proposed Project require crossing of any water body? ___Yes ___No

    If "Yes", check off the type of structure(s) or method(s) that will be used and identify on site diagram:

    ___Snow (SF) and/or ice fills (IF)
    ___Strapped or cabled log fills (LF)
    ___Ford type crossings (F)
    ___Log crossing (LC)
    ___Portable free-span bridge (PB)
    ___Existing bridge
    ___Non-mechanical crossing (NM)
    ___Other (describe):
  3. Is the project within a 1 in 100 year floodplain? ___Yes ___No
  4. Is the project located on native grassland? ___Yes ___No
  5. Are there problem soils? ___Yes ___No
  6. Is there a requirement to apply for and secure other federal permits and/or authorizations (e.g. Migratory Bird Convention Act, Species at Risk Act, Fisheries Act)? ___Yes ___No

    If "Yes", provide additional details and attach Appendix 12.
  7. Were any critical wildlife habitat features (dens, mineral licks, snags, etc.) identified? ___Yes ___No
  8. Is the project located on lands where there are known or suspected archaeological resources? ___Yes ___No

    If "Yes", was a determination of archaeological potential completed by a qualified Archaeologist? ___Yes ___No
  9. Was a culturally significant site or archaeological/historical resource identified during the site visit or is likely to be affected by the project activities? ___Yes ___No
  10. Does the project overlap with lands with any other special designations? ___Yes ___No
  11. Is the project considered a non-standard size? ___Yes ___No
  12. Were any non-standard mitigation measures discussed with a representative from the IOGC environment unit prior to this application? ___Yes ___No

    If "Yes," provide details:







Section D. First Nation Contact Information, Traditional Ecological Knowledge, Resident Consultation and Communication with Community

  1. First Nation Contact Information

    Contact Name:__________________________
    Job Title:__________________________
    Phone #:__________________________
    Email:__________________________
  2. Site Visit and Traditional Ecological Knowledge (TEK)
    1. Site Visit
      1. List names and titles of First Nation Representative present during the site visit:__________________________
      2. Date(s) of site visit:__________________________
    2. TEK
      1. List name(s) of other First Nation Elder or other First Nation Representative and date(s) contacted:__________________________
      2. Describe how TEK has been and will be considered in project planning and the life of the project:__________________________
    3. Confirm all TEK setbacks will be met:
      ___Yes ___No If "No", describe mitigation:







  3. Resident Consultation and Communication with Community
    1. Have all on-Reserve residents within a 500 m radius (100 m for RW) been consulted and their concerns addressed? ___Yes ___No ___N/A
      If 'No’, describe:



    2. If there are any residents within a 500 m radius (100 m for RW), confirm the 'Resident Consultation Table’ is attached as Appendix 3. ___Yes ___N/A
    3. Describe on-going community consultation and/or communication plans:





Section E. Site-Specific Environmental Information

  1. Topography
    1. Topography:

      ___Level
      ___Rolling
      ___Hummocky
      ___Inclined
      ___Ridged
      Other (describe):__________________________
    2. Predominant slope (direction, position, and percentage (%)/degree (°):__________________________
    3. Elevation change (high end to low end of lease):__________________________
    4. Potential stability issues:
      ___Yes ___No If "Yes", describe:





  2. Soils
    1. Site-specific soil evaluation completed
      Confirm it is attached as Appendix 4: ___Yes ___Not applicable (For seismic/exploratory only)
    2. Erosion potential:
      ___Insignificant
      ___Slight
      ___Moderate
      ___High
      ___Extreme
    3. Erosion control required?

      ___Yes ___No If "Yes", describe:




    4. Soil stripping required? ___Yes ___No
      If "Yes", what type of soil stripping?
      ___Two lift
      ___Single lift
      ___Other:
      If "Single lift" or "Other", describe in detail and provide rationale:





    5. Soil Drainage:

      ___Rapid
      ___Well
      ___Moderately well
      ___Imperfect
      ___Poor
      ___Very poor
  3. Hydrology
    1. What is the distance to the closest waterbody from the edge of the surface agreement?__________________________
    2. Is there a waterbody less than 100 m from the edge of the surface agreement? ___Yes ___No

      If "Yes", fill out the information below:
      Distance of high water mark:__________________________
      Size/Dimensions (m):__________________________
      Approximate depth:__________________________
      If wetland, identify the class:__________________________ ___N/A
      Is the waterbody fish-bearing? ___Yes ___No
      Is the project up- or down-slope from waterbody?__________________________
      Confirm waterbody and riparian zone photographs are included in Appendix 10: ___Yes
    3. Is there any evidence of any natural springs in the project area? ___Yes ___No

      If "Yes", what is the distance from the edge of the surface agreement?__________________________
  4. Hydrogeology
    1. Are there any water wells with 500 m of well centre or seismic/exploratory program? ___Yes ___No

      If "Yes",__________________________
      1. list distance(s) in m:__________________________
      2. Below Ground Level (BGL) depth of each water well:__________________________
      3. Confirm pre-drilling water well testing results are attached as Appendix 11. ___Yes
  5. Vegetation and Surrounding Land Use
    1. Vegetation type (check all that apply):

      ___Native grassland
      ___Peatland/muskeg
      ___Sparsely- or non-vegetated

      Cultivated (choose one):

      ___Hayland
      ___Tame Pasture
      ___Cropland
      ___Cut block
      ___Forest
      ___Other
      Describe:




    2. If cultivated (includes crops, hayland, tame pasture):

      % native species and % cultivated/forage species ___% and ___%
      Date last seeded:__________________________
      Location and quantity of native prairie/parkland within 1 km:__________________________
      List dominant species and percent cover:
    3. If forested:

      Merchantable timber present ___Yes ___No

      If "Yes", provide a volume inventory as follows:
      Coniferous approx. volume: ___m³ or ___no. loads Spruce ___% Pine ___%

      Coniferous Average DBH (diameter at breast height):
      Deciduous approx. volume: ___m³ or ___no. loads Aspen ___% Other ___%

      Deciduous DBH:__________________________
      Describe salvageable timber handling:__________________________
      Describe non-salvageable timber handling:__________________________
      List dominant species and percent cover:__________________________
    4. If native grassland:

      % native species: % tame species (if applicable) ___% : ___%
      List dominant species and percent cover:




    5. If Peatland:

      List dominant species and percent cover:




  6. Weeds, Invasive, and Problem Species
    1. Were any weeds, invasive, and problem species identified on or near the proposed surface agreement? ___Yes ___No

      If "Yes", list species of concern, provincial Weed Act classification, percent cover, and describe species-specific weed monitoring and management in Appendix 6.
  7. Wildlife and Wildlife Sign
    1. Describe wildlife and wildlife sign observed during the site visit in the table below. Use Appendix 13 if additional space is required.
      Common Name Scientific Name Location and distance to project Observation Type Comments
               
               
               
               
               
  8. Species at Risk (Vegetation, Wildlife, and Fish)
    1. Do any species at risk have potential habitat or ranges within the proposed project area? ___Yes ___No
      If "Yes", attach as Appendix 5.
  9. Fish and Fish Habitat
    1. Will the project impact fish habitat? ___Yes ___No
      If "Yes", provide details and attach Appendix 12.

Section F. Amendment, Additional Well/Pipeline, Change of use, and Expiry of Environmental Protection Terms

  1. Type of amendment, additional well/pipeline or change of use:
    ___New well(s)
    1. # of new wells:__________________________
      ___New pipeline within existing right of way
    1. Size of pipeline:__________________________
    2. Product:__________________________
    ___New lands
    1. Provide New ha:__________________________
    2. Provide Total ha:__________________________
    3. Will all setback, timing, and environmental requirements as per Section 7 in the Guide be met? ___Yes ___No
      If "No", include non-standard mitigation measures as Appendix 5.
    4. Is the size of addition >10 % of the original surface agreement? ___Yes ___No

      If "No", continue completing remainder of this section.
      If "Yes", STOP HERE and complete the full Environmental Review Form (sections A-H) including new site visit information.
    ___Change of use
    1. Describe change of use:__________________________
      ___Horizontal multi-stage fracture
      ___Environmental Protection Terms Letter has expired (project not undertaken within 1.5 years of date of letter)
  2. Confirm First Nation Oil and Gas Representative has been notified. ___Yes
  3. Are there any residents living within the consultation radii (100 m for pipelines, 500 m for surface leases or seismic/exploratory)? ___Yes ___No
    If "Yes", attach Appendix 3.
  4. For a seismic or well program, have water wells within 500 m of the project been tested (as per section E.4.a)? ___Yes ___N/A
    If "Yes", attach as Appendix 11.
  5. Have any new species with ranges within the regional area been added to the Species at Risk Act list subsequent to the original approval? ___Yes ___No
    If "Yes", attach Appendix 5.
  6. Is there any aspect of the project that has changed from the original application? ___Yes ___No
    If "Yes", describe:




  7. Is there any other information relevant to the project, that IOGC should be aware of? ___Yes ___No
    If "Yes", describe:




Section G. Appendices

Appendix 1 - Project Activities and Duration Table ___Yes ___N/A

Appendix 2 - Potential Impacts, Mitigation, and Related Residual Effects Table ___Yes ___N/A

Appendix 3 - Resident Consultation Summary Table ___Yes ___N/A

Appendix 4 - Soil Evaluation ___Yes ___N/A

Appendix 5 - Potential Species at Risk within the Proposed Project Area Table ___Yes ___N/A

Appendix 6 - Additional Mitigation Measures ___Yes ___N/A

Appendix 7 - Survey Plan ___Yes ___N/A

Appendix 8 - Aerial Photographs and Maps ___Yes ___N/A

Appendix 9 - Site Diagram(s) ___Yes ___N/A

Appendix 10 - Site Photographs ___Yes ___N/A

Appendix 11 - Pre-construction Water Well Test Results ___Yes ___N/A

Appendix 12 - Correspondence/Permits from Other Federal Departments ___Yes ___N/A

Appendix 13 - Pre-Development Surveys or Third-Party Reports ___Yes ___N/A

Appendix 14 - Additional Information ___Yes ___N/A

Section H. Presentation of the Environmental Review

To be completed by the Applicant:

I hereby certify that the information provided is accurate and complete.

I hereby certify on behalf of the Applicant, all mitigation measures described in Appendices 2 and 6 will be implemented and will not cause any significant adverse environmental impacts.

Signature:__________________________
Name:__________________________
Date:__________________________
Title:__________________________
Organization:__________________________
Address:__________________________
Phone number:__________________________
Email:__________________________

To be completed by the Qualified Environmental Professional: Footnote 1

I hereby certify that the information provided in this application is accurate, complete, and corresponds to my interpretation of the project.

I hereby certify that the proposed project will not cause any significant adverse environmental impacts.

Signature and professional association # or stamp:__________________________
Name:__________________________
Date:__________________________
Title:__________________________
Organization:__________________________
Address:__________________________
Phone number:__________________________
Email:__________________________

Has a copy of the Environmental Review Form been forwarded to the First Nation Chief and Council care of the Oil and Gas Representative? ___Yes ___No

Section I. Decision

TO BE COMPLETED BY INDIAN OIL AND GAS CANADA

I have analysed the project and its potential environmental effects and/recommend that:

  1. The project is not likely to cause significant adverse environmental impacts and can be implemented as described with the application of the proposed mitigation measures _____.
  2. The project should undergo a detailed environmental review, based on the information below _____.
  3. The project is likely to cause significant adverse environmental impacts which are unable to be mitigated _____.
  4. This application is incomplete due to:__________________________

Signature:__________________________
Name:__________________________
Date:__________________________
Title: Environmental Analyst
Phone number: 403.292.________
Contact with First Nation Oil and Gas Representative:__________________________
Date:__________________________

To be completed by the Manager, Environment

I recommend that:

  1. The project is not likely to cause significant adverse environmental impacts and can be undertaken with the implementation of the proposed mitigation measures ____.
  2. The project should undergo a detailed environmental review, as recommended ____.
  3. The project is likely to cause significant adverse environmental impacts which are unable to be mitigated and is not approved as proposed ____.

Signature:__________________________
Date:__________________________

Additional Information/Rationale/Notes/Documents:

 

 

 

EX___ OS___ RW___ #:__________________________
Reserve name and number:__________________________
Project Location:__________________________
Company:__________________________
File #: E5010-6-0__________________________UNC.
CIDM#:__________________________
PA’d:___

Date modified: