Free 50616.pdf - Indiana

APPLICATION FOR APPROVAL TO CONDUCT COAL EXPLORATION ACTIVITIES
State Form 50616 (R2 / 9-08)

Indiana Department of Natural Resources Division of Reclamation Approval Number EExcavation - Yes __ _ No Core Drilling - Yes __ _ No __ _

REMOVING LESS THAN 250 TONS OF COAL BY PIT EXCAVATION OR CORE DRILLING

(1) (2)

Applicant's Name: Address of Applicant:

(3)

Telephone Number:

(4) Name, address and telephone number of the representative(s) of the applicant who will be present at and responsible for conducting the exploration activities:
Name Address Telephone No.

(5) Legal description by 1/4, 1/4 Section(s), Township(s), and Range(s) of the exploration area (Specific section, township, range for core drilling):

(6) (8) (9)

County: __________________ (7) U.S.G.S. Quadrangle: _________________ Approximate acres to be disturbed: _______________ Approximate number of holes and depth: ____________ ______________

(10) Describe the type(s) of exploration activity to be conducted including the type of equipment to be used, the amounts of coal to be removed, the location of testing facilities and the measures to be used to comply with applicable requirements of 312 IAC 25-6-1 through 25-6-4, including core hole plugging procedures and a cross-section of plugged holes: (11) Describe the estimated timetable for conducting and completing each phase of exploration and reclamation in (10). For core drilling, an annual notice is required and should be specific to those areas needed during any given year:

(12) A plugging affidavit as contained in the procedures statement on exploratory activity must be submitted to the Division on each hole drilled within 30 days of final plugging. (13) Submit a copy of a U.S.G.S. 7.5 minute topographic map of the proposed exploration area at a scale of 1 inch = 2,000 feet or larger. The map must show the boundaries of the exploration area, the location of existing and proposed roads and access routes, and the location of all existing lakes, ponds and streams, and drainage features in the area of proposed exploration. (For excavations or holes in excess of 200')

I ___________________________________________ , hereby affirm that all statements and
(typed or printed name of responsible official),

representations made in this application and attachments thereto are true and correct to the best of my information and belief. Applicant: Signed: Title:

Subscribed and sworn to before me this _______ day of _____________________, 20_____. My commission expires .

Notary Public Signature

Name Typed or Printed

Residence: County
__________________________

State