Form A-2 "Notification of Flowback Fluid and Frac Sand Disposal" - Saskatchewan, Canada

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Download Form A-2 "Notification of Flowback Fluid and Frac Sand Disposal" - Saskatchewan, Canada

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FORM A-2: NOTIFICATION OF FLOWBACK FLUID AND FRAC SAND DISPOSAL
1. WELL INFORMATION
OWNER NAME
Well Licence
Well Licensee:
Number:
LX
LSD
SEC
TWP
RGE
MER
DATE
MONTH
YEAR
Surface
Location:
W
Disposal Date:
2. COMPANY INFORMATION
CHOOSE THE APPROPRIATE SEM FIELD OFFICE TO SUBMIT FORM
OPERATOR CONTACT
o AREA 1 LLOYDMINSTER
COMPANY NAME
o AREA 2 KINDERSLEY
o AREA 3 SWIFT CURRENT
PHONE NUMBER
o AREA 4 ESTEVAN FAX
EMAIL ADDRESS
3. FRAC FLUID SYSTEM INFORMATION
FRAC FLUID SYSTEM TYPE
ADDITIVE INFORMATION
CONTAINMENT FEATURES
o WATER BASED
o OIL
o OPEN TOP TANK
o FOAM
o ACID
o ENCLOSED TANK
o MIXED-BASED
o METALS
TANK SPACING
o CROSSLINKED
o TDGR DANGEROUS GOODS
o 23 METRES FROM WELL HEAD
o POLYEMULSION
o AECB REGULATED MATERIAL
o 45 METRES FROM WELL HEAD
o OIL BASED
4. FLOWBACK FLUID DISPOSAL INFORMATION
5. FRAC SAND DISPOSAL INFORMATION
TOTAL FLUIDS VOLUME
TOTAL FRAC SAND VOLUME
3
3
m
m
DISPOSAL METHOD
WPF/MRO
DISPOSAL METHOD
WPF/MRO
o WASTE PROCESSING FACILITY
o WASTE PROCESSING FACILITY
o ML1 DISPOSAL
o COMPANY OWNED DISPOSAL WELL
(SPECIFY MUNICIPALITY)
o MUNICIPAL LANDFILL
(SPECIFY COMPANY)
o NON-SEM APPROVED LANDFARM
SPECIFY LOCATION & MRO NO.:
(SPECIFY)
o OTHER METHOD
_________________________________________________
SPECIFY:
_________________________________________________
__________________________________________
o ML2 DISPOSAL
o 3RD PARTY DISPOSAL WELL
(COMPANY AND LOACTION)
o COMMERCIAL LANDFILL
pH: ______________________________________
(SPECIFY WPF NO.)
o SEM APPROVED LANDFARM
FLASH POINT: ___________________________°C
o RSD METHOD
(SUBMIT FORM A-1)
o OTHER METHOD
(SPECIFY)
SPECIFY LOCATION & MRO NO.:
SPECIFY:
________________________________________________
__________________________________________
6. FRAC SAND ANALYTICAL INFORMATION FOR ML1 AND ML2 DISPOSAL METHOD
pH
SODIUM ADSORPTION RATIO
TOTAL EXTRACTABLE HYDROCARBON
mg/kg
ELECTRICAL CONDUCTIVITY
FLASH POINT
MICROTOX
°C
o PASS
o FAIL
dS/m
7. CERTIFICATION INFORMATION
The operator shall submit this form within 30 days of completion of the frac operation as part of the frac report.
I hereby certify that I am authorized to represent the above mentioned well licensee and I certify that the information
submitted herein application is correct and accurate to the best of my knowledge. I understand that if the flowback fluid
and/or frac sand is/are disposed incorrectly (disposed in a manner contrary to this guideline, other applicable waste
management guidelines or applicable regulatory/legislative requirements) the well licensee will be responsible to
implement mitigative measures prescribed by Saskatchewan Energy and Mines.
NAME (PRINT):
SIGNATURE:
FORM A-2: NOTIFICATION OF FLOWBACK FLUID AND FRAC SAND DISPOSAL
1. WELL INFORMATION
OWNER NAME
Well Licence
Well Licensee:
Number:
LX
LSD
SEC
TWP
RGE
MER
DATE
MONTH
YEAR
Surface
Location:
W
Disposal Date:
2. COMPANY INFORMATION
CHOOSE THE APPROPRIATE SEM FIELD OFFICE TO SUBMIT FORM
OPERATOR CONTACT
o AREA 1 LLOYDMINSTER
COMPANY NAME
o AREA 2 KINDERSLEY
o AREA 3 SWIFT CURRENT
PHONE NUMBER
o AREA 4 ESTEVAN FAX
EMAIL ADDRESS
3. FRAC FLUID SYSTEM INFORMATION
FRAC FLUID SYSTEM TYPE
ADDITIVE INFORMATION
CONTAINMENT FEATURES
o WATER BASED
o OIL
o OPEN TOP TANK
o FOAM
o ACID
o ENCLOSED TANK
o MIXED-BASED
o METALS
TANK SPACING
o CROSSLINKED
o TDGR DANGEROUS GOODS
o 23 METRES FROM WELL HEAD
o POLYEMULSION
o AECB REGULATED MATERIAL
o 45 METRES FROM WELL HEAD
o OIL BASED
4. FLOWBACK FLUID DISPOSAL INFORMATION
5. FRAC SAND DISPOSAL INFORMATION
TOTAL FLUIDS VOLUME
TOTAL FRAC SAND VOLUME
3
3
m
m
DISPOSAL METHOD
WPF/MRO
DISPOSAL METHOD
WPF/MRO
o WASTE PROCESSING FACILITY
o WASTE PROCESSING FACILITY
o ML1 DISPOSAL
o COMPANY OWNED DISPOSAL WELL
(SPECIFY MUNICIPALITY)
o MUNICIPAL LANDFILL
(SPECIFY COMPANY)
o NON-SEM APPROVED LANDFARM
SPECIFY LOCATION & MRO NO.:
(SPECIFY)
o OTHER METHOD
_________________________________________________
SPECIFY:
_________________________________________________
__________________________________________
o ML2 DISPOSAL
o 3RD PARTY DISPOSAL WELL
(COMPANY AND LOACTION)
o COMMERCIAL LANDFILL
pH: ______________________________________
(SPECIFY WPF NO.)
o SEM APPROVED LANDFARM
FLASH POINT: ___________________________°C
o RSD METHOD
(SUBMIT FORM A-1)
o OTHER METHOD
(SPECIFY)
SPECIFY LOCATION & MRO NO.:
SPECIFY:
________________________________________________
__________________________________________
6. FRAC SAND ANALYTICAL INFORMATION FOR ML1 AND ML2 DISPOSAL METHOD
pH
SODIUM ADSORPTION RATIO
TOTAL EXTRACTABLE HYDROCARBON
mg/kg
ELECTRICAL CONDUCTIVITY
FLASH POINT
MICROTOX
°C
o PASS
o FAIL
dS/m
7. CERTIFICATION INFORMATION
The operator shall submit this form within 30 days of completion of the frac operation as part of the frac report.
I hereby certify that I am authorized to represent the above mentioned well licensee and I certify that the information
submitted herein application is correct and accurate to the best of my knowledge. I understand that if the flowback fluid
and/or frac sand is/are disposed incorrectly (disposed in a manner contrary to this guideline, other applicable waste
management guidelines or applicable regulatory/legislative requirements) the well licensee will be responsible to
implement mitigative measures prescribed by Saskatchewan Energy and Mines.
NAME (PRINT):
SIGNATURE: