Form 27 - Remediation Workplan
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Tracking Number: ________________________________________
FORM
State of Colorado
Name of Operator: ________________________________________
27
Oil and Gas Conservation Commission
Rev 6/99
OGCC Operator No: ______________________________________
1120 Lincoln Street, Suite 801, Denver, Colorado 80203
(303)894-2100
Fax:(303)894-2109
Received Date: __________________________________________
Page 2
Well Name & No: _________________________________________
REMEDIATION WORKPLAN (Cont.)
Facility Name & No: _______________________________________
OGCC Employee:
If groundwater has been impacted, describe proposed monitoring plan (# of wells or sample points, sampling schedule, analytical methods, etc.):
Describe reclamation plan. Discuss existing and new grade recontouring; method and testing of compaction alleviation; and reseeding program,
including location of new seed, seed mix and noxious weed prevention. Attach diagram or drawing. Use additional sheet for description if required.
Attach samples and analytical results taken to verify remediation of impacts. Show locations of samples on an onsite schematic or drawing.
Is further site investigation required?
Y
N
If yes, describe:
Final disposition of E&P waste (landtreated and disposed onsite, name of licensed disposal facility, recycling, reuse, etc.):
IMPLEMENTATION SCHEDULE
Date Site Investigation Began: _____________
Date Site Investigation Completed: ___________
Date Remediation Plan Submitted: ___________
Remediation Start Date: __________________
Anticipated Completion Date: ________________ Actual Completion Date: ___________________
I hereby certify that the statements made in this form are, to the best of my knowledge, true, correct, and complete.
Print Name: _________________________________________ Signed: ________________________________________
Title:__________________________________________ Date:_____________________
OGCC Approved: ________________________________ Title:________________________________ Date:_____________
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