PFBC USE ONLY
PENNSYLVANIA FISH AND BOAT COMMISSION
PROJECT NUMBER
PRELIMINARY PROJECT OFFER
Natural Gas Lease and/or Water Access Opportunities
FISCAL YEAR
RECEIVED
Form PFBC-NGWA-1
REV (7/11)
Complete all sections that apply to the proposed project. Please refer to the Natural Gas Lease and/or Water Access Opportunities Preliminary Project Offer Guidelines document for additional instructions.
A. – APPLICANT INFORMATION
APPLICANT OR ENTITY NAME
TELEPHONE NUMBER
MAILING ADDRESS 1
MAILING ADDRESS 2 (IF APPLICABLE)
CITY
STATE
ZIP CODE
PROJECT MANAGER (PERSON IN CHARGE OF THE PROJECT)
FAX NUMBER
EMAIL ADDRESS
TITLE
EMAIL ADDRESS
TELEPHONE NUMBER
IDENTIFY PERSON WHO WORKS CLOSELY WITH PROJECT MANAGER THAT CAN BE CONTACTED WHEN ISSUES ARISE THROUGHOUT THE PROJECT’S
PHASES. THIS PERSON CAN BE CONTACTED IN LIEU OF THE PROJECT MANAGER FOR ANSWERS.
NAME
TITLE
EMAIL ADDRESS
TELEPHONE NUMBER
B. – CONSULTANT INFORMATION (Complete only if consultant is hired to work on applicant’s behalf)
NAME
TELEPHONE NUMBER
MAILING ADDRESS 1
MAILING ADDRESS 2 (IF APPLICABLE)
CITY
STATE
ZIP CODE
PROJECT MANAGER (PERSON IN CHARGE OF THE PROJECT)
FAX NUMBER
EMAIL ADDRESS
TITLE
C. – PROJECT TYPE (Check all that apply)
NATURAL GAS LEASE*
WATER ACCESS
STORAGE
TRANSMISSION
*FOR GAS LEASING OFFERS, THE COMMISSION REQUEST A LEASE HOLD MAP OF THE SURROUNDING AREA BE INCLUDED, AND THAT PRODUCTION RATES FOR NEARBY
WELLS BE PROVIDED, IF KNOWN.
*WHAT, IF ANY, TITLE VERIFICATION WORK HAS BEEN CONDUCTED?
D. – PROJECT LOCATION
PFBC PROPERTY NAME
LATITUDE (IN DECIMAL DEGREES)
COUNTY
LONGITUDE (IN DECIMAL DEGREES)
TOWNSHIP
WATERBODY
ESTIMATED NUMBER OF ACRES OWNED BY PFBC
PROJECT ADDRESS OR ROAD INTERSECTION DESCRIPTION
Form PFBC-NGWA-1, Preliminary Project Offer
Page 1 of 3
E. – PROJECT DESCRIPTION (SEE PRELIMINARY PROJECT OFFER GUIDELINES)
DESCRIPTION SHOULD INCLUDE:
 A general overview of what is being proposed.
 How and when the project will be implemented and managed.
 How the proposed project may be designed to benefit anglers, boaters, local residents and the resource, and the
habitat improvements, infrastructure improvements, or maintenance contributions being considered.
 How the proposed project may be designed to be of value to conservation efforts.
 How you plan to incorporate public involvement in the planning and implementation process.
 If a water access and withdrawal project, provide the estimated amount of water needed and a general concept of
the required infrastructure.
 If a gas production project, show how the project relates to development plans in the area
 If available, indicate the size of the project (acres of land, miles of riparian corridor), and provide a map.
ATTACH ADDITIONAL SHEETS AS REQUIRED
Form PFBC-NGWA-1, Preliminary Project Offer
Page 2 of 3
F. – ENVIRONMENTAL ASSESSMENT
Provide a site map showing area to be affected and proposed activities for the site. (REQUIRED)
1. WILL THE PROJECT SIGNIFICANTLY AFFECT WATER QUALITY?
2. WILL THE PROJECT SIGNIFICANTLY AFFECT AIR QUALITY?
3. WILL THE PROJECT SIGNIFICANTLY AFFECT WILDLIFE, FISH, OR AQUATIC LIFE?
4. WILL THE PROJECT SIGNIFICANTLY AFFECT LAND USE?
5. WILL THE PROJECT RESULT IN SIGNIFICANT ADDITIONAL LONG-TERM NOISE?
6. WILL THE PROJECT RESULT IN SIGNIFICANT SAFETY OR LAW ENFORCEMENT IMPACTS?
7. WILL THE PROJECT RESULT IN SIGNIFICANT RECREATIONAL USE CONFLICTS?
8. WILL THE PROJECT SIGNIFICANTLY CREATE AN ENVIRONMENTAL HAZARD?
9. ARE OVERHEAD UTILITIES LOCATED AT THE FACILITY THAT WOULD POSE A HAZARD TO PEOPLE OR BOAT MASTS?
10. WILL ANY HAZARDOUS MATERIALS BE USED TO DEVELOP, OPERATE OR MAINTAIN THE OPERATION?
11. WILL THE PROJECT SIGNIFICANTLY AFFECT HABITAT including the protection of threatened or endangered species?
a. Does your site plan include ways to control and manage invasive species?
PLEASE ELABORATE TO THE EXTENT OF THE SIGNIFICANT EFFECT(S) TO ANY QUESTION IDENTIFIED AS “YES” ABOVE
YES
NO
LIST ALL ENVIRONMENTAL VIOLATIONS, CITATIONS OR INCIDENTS BY APPLICANT OR AFFILIATED COMPANY WITHIN THE PAST 24
MONTHS
G. – PRELIMINARY CONSIDERATION OFFER
NATURAL GAS
ACCESS TO WATER ON PFBC
PROPERTY
ACCESS ACROSS PFBC PROPERTY
TO COMMONWEALTH WATER
AMOUNT
PER ACRE LEASE
CAPITAL INVESTMENT
ROYALTIES (PROPOSED RATE)
OTHER
CAPITAL INVESTMENT
PER 1,000 GALLON ROYALTY RATE
ANNUAL FEE
OTHER
CAPITAL INVESTMENT
PER GALLON ROYALTIES
ANNUAL FEE
OTHER
SIGNATURE
This preliminary offer is made for the activities described herein. I certify that I am familiar with all the information contained in this offer
form, and to the best of my knowledge, information and belief, the offer form is true, complete, and accurate. I further certify that I
possess the authority to make this offer and to undertake the proposed activities.
PRINT/TYPE NAME
TITLE
SIGNATURE
DATE
C:\AS\Oil & Gas\NGWA_Preliminary_Project_Offer_Form_V13.doc
Form PFBC-NGWA-1, Preliminary Project Offer
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