Form 27 - Site Investigation And Remediation Workplan
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FORM
27
State of Colorado
FOR OGCC USE ONLY
Rev 6/99
Oil and Gas Conservation Commission
1120 Lincoln Street, Suite 801, Denver, Colorado 80203 (303)894-2100 Fax:(303)894-2109
SIT E INVESTIGATION AND REMEDIATION WORKPLAN
This form shall be submitted to the Director for approval prior to the initiation of site investigation and remediation
OGCC Employee:
activities. Form 27 is intended to be used whenever possible. Additional documentation will be required when large
Spill
Complaint
volumes of soil and groundwater have been impacted or involve large facilities with multiple source areas. See Rule
Inspection
NOAV
910. Attach as many pages as needed to fully describe the proposed work.
Tracking No:
CAUSE OF CONDITION BEING INVESTIGATED AND REMEDIATED
Spill or Release
Plug & Abandon
Central Facility Closure
Site/Facility Closure
Other
:___________________________
(describe)
OGCC Operator Number:____________________________________________________
Contact Name and Telephone:
Name of Operator:_________________________________________________________
___________________________________________
Address:_________________________________________________________________
No:_________________________________________
City:__________________________________________ State:_____ Zip:_____________
Fax:________________________________________
API Number: ___________________________________
County: _________________________________________________________
Facility Name: __________________________________
Facility Number: __________________________________________________
Well Name: ____________________________________
Well Number: ____________________________________________________
Location: (QtrQtr, Sec, Twp, Rng, Meridian): ___________________________________________ Latitude: ____________ Longitude: ___________
TECHNICAL CONDITIONS
Type of Waste Causing Impact (crude oil, condensate, produced water, etc): __________________________________________________________
Site Conditions: Is location within a sensitive area (according to Rule 901e)?
Y
N
If yes, attach evaluation.
Adjacent land use (cultivated, irrigated, dry land farming, industrial, residential, etc.): ____________________________________________
Soil type, if not previously identified on Form 2A or Federal Surface Use Plan: _________________________________________________
Potential receptors (water wells within 1/4 mi, surface waters, etc.): _________________________________________________________
_______________________________________________________________________________________________________________
Description of Impact (if previously provided, refer to that form or document):
Impacted Media (check):
Extent of Impact:
How Determined:
Soils
___________________________________________
________________________________________
Vegetation
___________________________________________
________________________________________
Groundwater
___________________________________________
________________________________________
Surface Water
___________________________________________
________________________________________
REMEDIATION WORKPLAN
Describe initial action taken (if previously provided, refer to that form or document):
Describe how source is to be removed:
Describe how remediation of existing impacts is to be accomplished, including removal and disposal at an injection well or licensed
facility, land treatment on site, removal of impacted groundwater, insitu bioremediation, burning of oily vegetation, etc.:
Submit Page 2 with Page 1
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