FORM 27 State of Colorado Oil and Gas Conservation Commission Rev 6/99 FOR OGCC USE ONLY 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 activities. Form 27 is intended to be used whenever possible. Additional documentation will be required when large volumes of soil and groundwater have been impacted or involve large facilities with multiple source areas. See Rule 910. Attach as many pages as needed to fully describe the proposed work. CAUSE OF CONDITION BEING INVESTIGATED AND REMEDIATED Spill or Release Plug & Abandon Central Facility Closure Site/Facility Closure OGCC Employee: Spill Inspection Tracking No: Complaint NOAV 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 American LegalNet, Inc. www.FormsWorkflow.com