ANRC Gas FRAC Application

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ANRC Gas FRAC Application Powered By Docstoc
					                       Arkansas Natural
                     Resources Commission
J. Randy Young, PE    101 East Capitol, Suite 350                     Phone: (501) 682-1611    Mike Beebe
Executive Director    Little Rock, Arkansas 72201                        Fax: (501) 682-3991     Governor
                      http://www.anrc.arkansas.gov/                E-mail: anrc@arkansas.gov




                      APPLICATION FOR NON-RIPARIAN WATER USE
                                       FOR
                          GAS WELL FRACTURE STIMULATION
                                       AND
                         HYDROSTATIC TESTING OF PIPELINES



        APPLICANT

                Name: ___________________________________________

                Company: ________________________________________

                Address: _________________________________________

                         _________________________________________

                         _________________________________________

                Phone #: (______) ____-________________

                Alternate #: (______) _____-_____________

                Facsimile #: (______) _____-_____________

                E-Mail: ______________________________________________



                                               Official Use Only
                                 Action ID#: ______________________
                                 Issue Date: ______________________
                                 Expiration: ______________________
PROJECT SUMMARY:
Brief narrative of project, to include start and end date, estimated volume, landowner name and
contact, and intended use location :
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

SOURCE WATER INFORMATION
Source Type:    (circle one)     New Pond              Existing Pond        Stream

Source Name: ___________________________________________________

Source Location:      (Access)          Lat: ______________ Lon: ______________

Section 1/4, Township & Range: ___________________ County: ___________

Landowner Name: _______________________________________________

Landowner Address: ______________________________________________

FOR PONDS: (estimated) Surface Area: ____________ Volume: _____________

         Pond Drainage Area: ____________ Levee Height: ________________

FOR STREAMS: (estimated) Seasonal Flow Rate: ________________________

                                 Basis of Estimate: ___________________________
                               (For new ponds, attach a plan view sketch)

PERMITS REQUIRED
List all permits required and status:

Federal:

State:

Local:

Other:

SUPPORT MATERIALS
Complete and attach a map which clearly depicts the diversion point, and the intended
use location. Should the diversion point be utilized for multiple use sites, these may be
displayed as individual points, or as a use area.
CONSERVATION PLAN

A water conservation plan must accompany all applications for non-riparian diversion.
The purpose of the conservation plan is to insure that excess surface water is not used
in a wasteful manner. The conservation plan should consist of a narrative, describing
specific components, devices, technologies or operating methods which promote
efficient utilization of the water source. Complete and attach a conservation plan
prior to submitting this application for processing.

DIVERSION INFORMATION
Pump: (circle one)     Portable/Trailer Mount                  Fixed

Pump Type: ___________ Pump hp: ___________ Discharge Diameter: ________

Maximum Rate of Diversion (gal/min or cfs): _________________________________

Number of Diversions Anticipated Annually:________________________________

Maximum Volume Water to be Diverted Annually:___________________________

Is Off-Stream Storage Intended: (circle one) Yes / No         Volume: _________________

        Off-Stream Storage Location:                __________________________________

        Off-Stream Storage Type:                    POND       TANK           OTHER _______

Start date of water diversion: ________________ End Date: __________________

Intended Use Area (radius or lat/long):_______________________________________

Hydrostatic Testing: (circle one)        Yes / No
        Discharge Location:         (Return Flow)    Lat: _____________ Lon: ____________




Application is hereby made for a permit or permits to authorize the work
described in this application. I certify that the information in this application
is complete and accurate. I further certify that I possess the authority to
undertake the work described herein or am acting as the duly authorized
agent of the applicant.



___________________________________________                            __________________
SIGNATURE OF APPLICANT                                                 DATE

				
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posted:9/16/2012
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