Environmental Review Form
Word Version (332 Kb, 14 Pages)
- The accurate completion of this form is required to conduct oil and gas activity on Indian Reserve land in Canada.
- This Form is designed to be completed with the Guide to Preparing an Environmental Review Form for Indian Oil and Gas Canada, May 2014 (Guide).
- The Applicant shall ensure that the environmental information contained herein is prepared by an Independent Qualified Environmental Professional as per the aforementioned Guide.
- Use additional space in Appendix 14 if required.
Section A. Project Identification
- Applicant name:__________________________
- Project name:__________________________
- 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:_______________ - Project location
- Legal land description:____________________________________________________
- Latitude and Longitude:____________________________________________________
- Reserve name and number:____________________________________________________
- Anticipated start date or quarter:_______________
- Date(s) of site visit(s):_______________
- Type of application (See Section C):
___Standard application
___Non-standard application
Section B. Project Description
- Project Type:__________________________
- 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?_________ - Right of way
___Pipeline
Total size (ha):_________
Length (m) x width (m):_________
Outside diameter (mm):_________ - 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:__________________________ - Other
Describe:
- 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:
- Provide rationale for the project including how it was located to avoid surrounding environmental constraints.
Describe:
- Surface lease
-
Product:
___Oil
___Gas
___Sweet
___Sour (_______ % H2S)
___Produced water
___Other (describe): -
Describe all proposed project activities including duration (surveying to final reclamation):
Attach as Appendix 1 as per format described in Guide. -
Describe all potential impacts, mitigation, and related residual effects:
Attach as Appendix 2 as per format described in Guide. -
Drilling and Completion Fluids
- Drilling fluid:
___Not applicable (N/A)
___Gel chem
___Invert
___KCl
___Other: -
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):
-
Hydraulic fracturing
___N/A
___Applicable
- Number of stages:__________________________
- Estimated total fluid/sand volume of each stage:__________________________
- Describe how the frac fluid will be handled and stored to prevent contamination:__________________________
- What is vertical distance between the deepest water well and the depth of the fractured zone?__________________________
- Drilling fluid:
- 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:
-
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:
- If "Yes" is checked off in any of the following questions, this application will be processed as non-standard.
- For non-standard applications, Appendix 6 additional mitigation measures are required to be included as per format described in Guide.
- Are any variances for setback, timing, or environmental requirements as per Section 7 of the Guide required? ___Yes ___No
- 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): - Is the project within a 1 in 100 year floodplain? ___Yes ___No
- Is the project located on native grassland? ___Yes ___No
- Are there problem soils? ___Yes ___No
- 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. - Were any critical wildlife habitat features (dens, mineral licks, snags, etc.) identified? ___Yes ___No
- 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 - 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
- Does the project overlap with lands with any other special designations? ___Yes ___No
- Is the project considered a non-standard size? ___Yes ___No
- 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
- Detail on how any concerns were addressed must be included in Appendix 3.
- First Nation Contact Information
Contact Name:__________________________
Job Title:__________________________
Phone #:__________________________
Email:__________________________ - Site Visit and Traditional Ecological Knowledge (TEK)
- Site Visit
- List names and titles of First Nation Representative present during the site visit:__________________________
- Date(s) of site visit:__________________________
- TEK
- List name(s) of other First Nation Elder or other First Nation Representative and date(s) contacted:__________________________
- Describe how TEK has been and will be considered in project planning and the life of the project:__________________________
- Confirm all TEK setbacks will be met:
___Yes ___No If "No", describe mitigation:
- Site Visit
-
Resident Consultation and Communication with Community
- 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:
- 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
- Describe on-going community consultation and/or communication plans:
- Have all on-Reserve residents within a 500 m radius (100 m for RW) been consulted and their concerns addressed? ___Yes ___No ___N/A
Section E. Site-Specific Environmental Information
- Topography
- Topography:
___Level
___Rolling
___Hummocky
___Inclined
___Ridged
Other (describe):__________________________ - Predominant slope (direction, position, and percentage (%)/degree (°):__________________________
- Elevation change (high end to low end of lease):__________________________
- Potential stability issues:
___Yes ___No If "Yes", describe:
- Topography:
- Soils
- Site-specific soil evaluation completed
Confirm it is attached as Appendix 4: ___Yes ___Not applicable (For seismic/exploratory only) - Erosion potential:
___Insignificant
___Slight
___Moderate
___High
___Extreme - Erosion control required?
___Yes ___No If "Yes", describe: -
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:
- Soil Drainage:
___Rapid
___Well
___Moderately well
___Imperfect
___Poor
___Very poor
- Site-specific soil evaluation completed
-
Hydrology
- What is the distance to the closest waterbody from the edge of the surface agreement?__________________________
- 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 -
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?__________________________
- Hydrogeology
- Are there any water wells with 500 m of well centre or seismic/exploratory program? ___Yes ___No
If "Yes",__________________________- list distance(s) in m:__________________________
- Below Ground Level (BGL) depth of each water well:__________________________
- Confirm pre-drilling water well testing results are attached as Appendix 11. ___Yes
- Are there any water wells with 500 m of well centre or seismic/exploratory program? ___Yes ___No
- Vegetation and Surrounding Land Use
- 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:
- 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: - 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:__________________________ - If native grassland:
% native species: % tame species (if applicable) ___% : ___%
List dominant species and percent cover:
- If Peatland:
List dominant species and percent cover:
- Vegetation type (check all that apply):
- Weeds, Invasive, and Problem Species
- 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.
- Were any weeds, invasive, and problem species identified on or near the proposed surface agreement? ___Yes ___No
- Wildlife and Wildlife Sign
- 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
- Describe wildlife and wildlife sign observed during the site visit in the table below. Use Appendix 13 if additional space is required.
- Species at Risk (Vegetation, Wildlife, and Fish)
- Do any species at risk have potential habitat or ranges within the proposed project area? ___Yes ___No
If "Yes", attach as Appendix 5.
- Do any species at risk have potential habitat or ranges within the proposed project area? ___Yes ___No
- Fish and Fish Habitat
- Will the project impact fish habitat? ___Yes ___No
If "Yes", provide details and attach Appendix 12.
- Will the project impact fish habitat? ___Yes ___No
Section F. Amendment, Additional Well/Pipeline, Change of use, and Expiry of Environmental Protection Terms
- Do NOT complete for new projects.
- Type of amendment, additional well/pipeline or change of use:
___New well(s)- # of new wells:__________________________
___New pipeline within existing right of way
- Size of pipeline:__________________________
- Product:__________________________
- Provide New ha:__________________________
- Provide Total ha:__________________________
- 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. - 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.
- 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)
- # of new wells:__________________________
- Confirm First Nation Oil and Gas Representative has been notified. ___Yes
- 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. - 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. - 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. - Is there any aspect of the project that has changed from the original application? ___Yes ___No
If "Yes", describe:
- Is there any other information relevant to the project, that IOGC should be aware of? ___Yes ___No
If "Yes", describe:
Section G. Appendices
- See Guide for all Appendices requirements.
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
- IOGC and the First Nation must be informed of any changes to the project after the signature date.
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:
- 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 _____.
- The project should undergo a detailed environmental review, based on the information below _____.
- The project is likely to cause significant adverse environmental impacts which are unable to be mitigated _____.
- 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:
- The project is not likely to cause significant adverse environmental impacts and can be undertaken with the implementation of the proposed mitigation measures ____.
- The project should undergo a detailed environmental review, as recommended ____.
- 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:___