FORM 27 Rev 6/99 Page 2 State of Colorado Oil and Gas Conservation Commission 1120 Lincoln Street, Suite 801, Denver, Colorado 80203 (303)894-2100 Fax:(303)894-2109 REMEDIATION WORKPLAN (Cont.) Tracking Number: ________________________________________ Name of Operator: ________________________________________ OGCC Operator No: ______________________________________ Received Date: __________________________________________ Well Name & No: _________________________________________ Facility Name & No: _______________________________________ 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:_____________ American LegalNet, Inc. www.FormsWorkflow.com