identifyingww.4399

Page1of___AgencyUseOnlyFormWW-8(11-09)SiteRegistrationForm2)FacilityIDNumber:1)Date:3)DateReceived:STATEOFWESTVIRGINIADEPARTMENTOFENVIRONMENTALPROTECTION,OFFICEOFOILANDGASAPPLICATIONANDSITEREGISTRATIONFORLANDAPPLICATIONOFWATERPRODUCEDFROMCOALBEDMETHANEWELL4)FacilityOperator:5)FacilityName6)Operator'sFacilityNumber7)FacilityElevation8)Location:(a)Watershed(b)Districtc)County(d)Quadranglee)CoordinatesNAD831:9)SurfaceOwner*:10)AcreageAddress11)DesignatedAgent:AddressDESCRIPTIONOFAPPLICATIONAREA12)SoilType:SoilPermeability:DepthtoBedrock:DepthtoWaterTable:(InformationfromCountySoilSurveyReport)13)NearestWaterSupplyDistance*Type:StreamWellSpring14)NearestSurfaceWater*15)NearestOccupiedDwelling:16)AverageSlopeofProposedAreaofLandApplication:17)TotalAcreageofProposedApplicationArea:*Attachadditionalpagesasnecessary.
**Iflocatedwithin2500footradiusofthelandapplicationarea.
1Theattachedtopomap(See#18foradditionalrequirements)shallincludecoordinatesofboundariesforthelandapplicationarea,aswellasmonitoringwells(ifgroundwatermonitoringplanisproposed),monitoringmarkersforwater,soilandvegetationsampling.
Page2of___AgencyUseOnlyFormWW-8(11-09)SiteRegistrationForm2)FacilityIDNumber:1)Date:3)DateReceived:LOCATIONANDDESIGNMAP18)Attachamaponthescaleof1"=1,000'orgreatershowingtheacreagewithinthepermittedsitetobeusedforlandapplicationidentifyingallmonitoringpoints,surfacewaters,wells,springs,naturalrockoutcropsandpropertylinesinrelationtotheproposedareaoflandapplicationwithinaradiusof2500ft.
Thedrawingshallalsobesentindigitalformat,setupincoordinatesUTMZone17or18(asappropriate)andbasedonNorthAmericanDatum1983-NAD83.
Mapshallalsodelineateanybufferzonesandshowallwellsinvolvedinthedischarge.
DESCRIPTIONANDMETHODOFLANDAPPLICATION19)Provideanarrativedescribingthe:(a)NumberandAPINo.
ofallwellscontributingtothedischarge.
(b)Coalseamorseamsbeingproduced.
(c)Producedwatertreatmentsystemandchemicalstobeused(ifany).
(d)Methodandrateplannedforlandapplicationofproducedwater.
(e)Vegetationstudy,toincludebothbackgroundandbaselineconditionsfortheplannedapplicationareapriortoanylandapplication.
(f)Groundwatermonitoringplan,ifnecessarytoexceedcertaindischargelimitsasoutlinedinthepermitandfactsheet.
(g)Plannedbeginningdateoflandapplication.
MONITORINGPLAN20)ProducedWaterDischarge:(a)Thepointorareaatwhichtheproducedwateristobedischargedtothelandapplicationareaistobebothidentifiedinthenarrativeandshownonthedesignmap.
Thisdischargepointorareaistobeidentifiedbyapermanentmarkerwithasignattachedidentifyingthedischargepoint.
(b)Thegroundwater,soil,andvegetationmonitoringpointswithinthelandapplicationareaaretobelocatedbypermanentmarker.
Eachmonitoringpointistobeidentifiedbyauniqueidentifier,withthisidentifiershownuponthedesignmap.
Further,theindividualmonitoringpointsaretobeidentifiedinthelandapplicationareabyasignattachedtoeachpermanentmarker.
(c)Anarrativeistobeprovidedoutliningthemonitoringprogramofthelandapplicationareaforcontaminantconcentrationsinthesoilswithintheapplicationarea,toassurethatcontaminantsdischargedarenotadverselyaffectingsoilquality.
Inaddition,ifgroundwatermonitoringistobeconducted,thepermiteehastoincludeastudyincompliancewiththerequirementsfoundintheGeneralPermit(SeeGP-WV-1-07,H.
12–OtherRequirements);describingthemonitoringmethodsusedtoensurethatgroundwaterqualityisnotbeingadverselyaffectedbythelandapplication.
21)CoalbedProducedWater:(a)AnalyticalDataAttachsamplingandlaboratoryanalysisreporttoincludesampledate,time,methodofcollection,sampler,datereceivedatlab,dateofanalysis,andmethod.
ProvideanalysisforandincludeanticipatedrangeofconcentrationsfortheparametersrequiredinSectionBofthegeneralpermitGP-WV-1-07.
(b)DailyVolumesAnticipatedBasedOnPage3of___AgencyUseOnlyFormWW-8(11-09)SiteRegistrationForm2)FacilityIDNumber:1)Date:3)DateReceived:Actual22)Backgroundsampling:ForbackgroundmonitoringrequiredintheGeneralPermitGP-WV-1-07(H.
11–OtherRequirements,attachsamplingandlaboratoryanalysisreportsthatincludesampledate,time,methodofcollection,sampler,datereceivedatlab,dateofanalysis,andmethod.
ProvideanalysisforandincludeanticipatedrangeofconcentrationsfortheparametersrequiredinSectionBofthegeneralpermitGP-WV-1-07.
23)Providecalculationstosupportplannedapplicationratesgiventhesoilconditionsinthedischargearea.
CERTIFICATIONIcertifyunderpenaltyoflawthatthisdocumentandallattachmentswerepreparedundermydirectionorsupervisioninaccordancewithasystemdesignedtoassurethatqualifiedpersonnelproperlygatherandevaluatetheinformationsubmitted.
Basedonmyinquiryofthepersonorpersonswhomanagethesystem,orthosepersonsdirectlyresponsibleforgatheringtheinformation,theinformationsubmittedis,tothebestofmyknowledgeandbelief,true,accurate,andcomplete.
Iamawarethattherearesignificantpenaltiesforsubmittingfalseinformation,includingthepossibilityoffineandimprisonmentforknowingviolations.
OWNER/OPERATORName:By:Its:Date:STATEOFWESTVIRGINIACOUNTYOFto-wit:I,aNotaryPublicofsaidCounty,doherebycertifythatwhosignedthewritingaboveforbearingdatethe____of20___,hasthisdayinmysaidCounty,beforeme,acknowledgedthesaidwritingtobetheactanddeedofsaidcorporation.
Givenundermyhandandofficialsealthisthe_____dayof20____.
MycommissionexpiresNotaryPublic{SEAL}Page4of___AgencyUseOnlyFormWW-8(11-09)SiteRegistrationForm2)FacilityIDNumber:1)Date:3)DateReceived:VOLUNTARYSURFACEOWNERSTATEMENTOFAPPROVALIherebystatethatIhavereviewedthisapplicationforcoverageundergeneralpermitGP-WV-1-07forthedischargeofwaterproducedfromCoalbedMethaneWell(s)ontomysurfaceland.
Iunderstandthatbeforethepermitcoveragecanbegranted,theoperatormusthavemyconsenttotheapplicationoftheproducedwateronthesurfaceland.
IfurtherstatethatIhavenoobjectiontotheplanneddischargeofproducedwatertothelandsurfacedescribedinthesematerials,andIhavenoobjectiontocoverageundergeneralpermit#GP-WV-1-07beinggranted.
(Forexecutionbynaturalperson(s)(Forexecutionbycorporation,etc.
)Date:Name_(Signature)By:Date:(Signature)Its:Date_