STATE OF WEST VIRGINIA



STATE OF WEST VIRGINIA

DEPARTMENT OF ENVIRONMENTAL PROTECTION

DIVISION OF MINING AND RECLAMATION

FIELD REVIEW SITE QUESTIONNAIRE

(For Surface Coal Mine and Quarry Permits)

(W.Va. Code § 22 Articles 3 and 4)

| |      | |      |

|Applicant Name: | |SMA/QMA Permit No. | |

|Address: |      |

|(if mailing address is a P.O. Box, street address must be included) |      |

|City |      |State |   |Zip |      |Telephone No. |      |

|Contact Person and Phone Number: |      |

| |

|1. |Type of Permit or Application to be Reviewed: |

| |NOTE: This application must be completed for all of the following types of applications unless the exceptions as noted apply. |

| Surface Mine Application (Article 3) |

| Quarry Application (Article 4) |

| Incidental Boundary Revision (Article 3) or Quarry Modification (Article 4) |

| |Which involves more than five acres of land disturbance unless such land disturbance borders along the original permit boundary and is |

| |not a unit extension of the permit boundary as an appendage to the permit. |

| |Examples of unit extensions or appendages to the permit are: new roads, fills, staging or storage areas, new portals, etc. Proposed |

| |disturbances of greater than five acres on ridge tops or valley floors are subject to SHPO review regardless of purpose. |

| Permit Renewal (Article 3 only) - except as follows: |

| |Those on which all projected land disturbance has occurred prior to the renewal date; |

| |Those on which mining and/or land disturbance is not completed, but is documented to have had a prior SHPO review with findings of |

| |no existence of, or no effect on, historic or cultural resources. |

| Notice of Intent to Prospect (Article 3 only) - except as follows: |

| |Those which do not involve any land disturbance; |

| |Those which involve channel sampling along existing roadways, trails, tramways or existing benches, and where excavation by heavy |

| |equipment is not required for access or sampling; |

| |Those which involve only core drilling and are less than ten acres; |

| |Those in which land disturbance is proposed only on slopes of twenty degrees or greater in steepness |

|2. |Acres - Provide the following information of acres affected by this operation: |

| |*Total Disturbed Acres |      | |Total |      | | |      |

| |(check below) | |+ |Undisturbed Acres | |= |**TOTAL ACRES: | |

| * Previously Mined |      |Acres | |

| * Timbered |      |Acres | |

| * Other |      |Acres (Specify) |      |

| |*All previously disturbed area, including areas previously mined, timbered, etc. |

| |**Total Acres shall include all current and proposed acres affected by this operation. |

|3. A. |(Article 3 Only) |

| |Nature of Project: - Operation, method, and/or facility: |

| | | | | | | | | |

| SURFACE UNDERGROUND OTHER |

| |

| Area Mine Additional Opening Preparation Plant |

| | | | | | | | | |

| Mountaintop Refuse Disposal |

| | | | | | | | | |

| Contour Haulroad |

| | | | | | | | | |

| Steep Slope Impoundment |

| | | | | | | | | |

| Auger Loading Facility |

| | | | | | | | | |

| Other (Specify):       |

| | | | | | | | | |

|3. B. |(Article 4 Only) |

| |Nature of Project: - Operation, method, and/or facility: |

| | | | | | | | | |

| QUARRY OTHER |

| |

| New Operation Processing Area |

| | | | | | | | | |

| Modification Stockpile |

| | | | | | | | | |

| Spoil Disposal Area Haulroad |

| | | | | | | | | |

| Underground > 5 Ac. Impoundment |

| | | | | | | | | |

| Notice to Operate < 5 Ac. Loading Facility |

| | | | | | | | | |

| Other (Specify):       |

|4. Location of the Operation: |

|COUNTY |QUADRANGLE |NEAREST POST OFFICE |

|      |      |      |

| | |

|Latitude |    ( |   ' |    " | |Longitude |   ( |   ' |   " | |

| |

|5. |Maps - Include the following maps: |

| |One topographic map at a scale of 1" to 500', color coded to show the boundaries and extent of the proposed surface mining |

| |operation; |

| |One topographic map of a scale of 1" to 2000' (standard USGS topographic maps) which show the boundaries of the proposed operation. |

|6. |Include photographs of all structures (excluding trailers and temporary buildings, any structure built within the past twenty-five years, and |

| |equipment) situated on or adjacent to the proposed operation. NOTES: Adjacent in this context means within one-thousand feet of the proposed |

| |or permitted area. All photographs must be keyed to the project map. Indicate places where photographer stood and direction the camera was |

| |aimed. |

|7. |Indicate the features located on the proposed permit area: Check those that are present. |

| Building, outbuildings, foundations, structures, cellar-holes. |

| Petroglyphs (rock carvings), rock shelters or overhangs, cave entrances. |

| Earthworks or Indian Mounds. |

| Cemeteries or isolated graves. |

| Features of historic mining operations. |

| Other man-made features. Please specify in comments. |

| Areas of significant prior disturbance (when more than 20% of permit area). |

|8. |Are there any known archaeological or historic sites within 1000' of the permit area? |

| Yes No If Yes, attach explanation. |

|9. |Has this permit area been reviewed previously by the State Historic Preservation Office? |

| Yes No If Yes, provide the following: |

| |SMA/QMA Permit No. |      | |SHPO No.: |      |

|10. |Provide the date and individual's name who conducted the archaeological field pre-inspection |

|      |      |

|Date |Name |

NOTE: Applicant shall complete this form and include, along with appropriate maps, with all copies of the application. One separate copy of this completed form, along with appropriate maps, shall also be submitted to the regional DEP Office for SHPO notification.

IMPORTANT: The Department of Environmental Protection and the State Historic Preservation Office has agreed that DEP will directly communicate with SHPO on these requests. Requests received by SHPO from the applicant WILL NOT be reviewed by SHPO.

|DEP REGIONAL OFFICE ADDRESS: |

|Department of Environmental Protection |

|      |

|      |

|      |

|PHONE NO.:       |

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