Form C-141 "Release Notification" - New Mexico

What Is Form C-141?

This is a legal form that was released by the New Mexico Energy, Minerals and Natural Resources Department - a government authority operating within New Mexico. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 24, 2018;
  • The latest edition provided by the New Mexico Energy, Minerals and Natural Resources Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form C-141 by clicking the link below or browse more documents and templates provided by the New Mexico Energy, Minerals and Natural Resources Department.

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District I
State of New Mexico
Form C-141
1625 N. French Dr., Hobbs, NM 88240
Energy Minerals and Natural
District II
Revised August 24, 2018
811 S. First St., Artesia, NM 88210
Submit to appropriate OCD District office
Resources Department
District III
1000 Rio Brazos Road, Aztec, NM 87410
Oil Conservation Division
District IV
Incident ID
1220 S. St. Francis Dr., Santa Fe, NM 87505
1220 South St. Francis Dr.
District RP
Santa Fe, NM 87505
Facility ID
Application ID
Release Notification
Responsible Party
Responsible Party
OGRID
Contact Name
Contact Telephone
Contact email
Incident #
(assigned by OCD)
Contact mailing address
Location of Release Source
Latitude
Longitude
(NAD 83 in decimal degrees to 5 decimal places)
Site Name
Site Type
Date Release Discovered
API#
(if applicable)
Unit Letter
Section
Township
Range
County
Surface Owner:
State
Federal
Tribal
Private (Name:
)
Nature and Volume of Release
Material(s) Released (Select all that apply and attach calculations or specific justification for the volumes provided below)
Crude Oil
Volume Released (bbls)
Volume Recovered (bbls)
Produced Water
Volume Released (bbls)
Volume Recovered (bbls)
Is the concentration of dissolved chloride in the
Yes
No
produced water >10,000 mg/l?
Condensate
Volume Released (bbls)
Volume Recovered (bbls)
Natural Gas
Volume Released (Mcf)
Volume Recovered (Mcf)
Other (describe)
Volume/Weight Released (provide units)
Volume/Weight Recovered (provide units)
Cause of Release
District I
State of New Mexico
Form C-141
1625 N. French Dr., Hobbs, NM 88240
Energy Minerals and Natural
District II
Revised August 24, 2018
811 S. First St., Artesia, NM 88210
Submit to appropriate OCD District office
Resources Department
District III
1000 Rio Brazos Road, Aztec, NM 87410
Oil Conservation Division
District IV
Incident ID
1220 S. St. Francis Dr., Santa Fe, NM 87505
1220 South St. Francis Dr.
District RP
Santa Fe, NM 87505
Facility ID
Application ID
Release Notification
Responsible Party
Responsible Party
OGRID
Contact Name
Contact Telephone
Contact email
Incident #
(assigned by OCD)
Contact mailing address
Location of Release Source
Latitude
Longitude
(NAD 83 in decimal degrees to 5 decimal places)
Site Name
Site Type
Date Release Discovered
API#
(if applicable)
Unit Letter
Section
Township
Range
County
Surface Owner:
State
Federal
Tribal
Private (Name:
)
Nature and Volume of Release
Material(s) Released (Select all that apply and attach calculations or specific justification for the volumes provided below)
Crude Oil
Volume Released (bbls)
Volume Recovered (bbls)
Produced Water
Volume Released (bbls)
Volume Recovered (bbls)
Is the concentration of dissolved chloride in the
Yes
No
produced water >10,000 mg/l?
Condensate
Volume Released (bbls)
Volume Recovered (bbls)
Natural Gas
Volume Released (Mcf)
Volume Recovered (Mcf)
Other (describe)
Volume/Weight Released (provide units)
Volume/Weight Recovered (provide units)
Cause of Release
State of New Mexico
Form C-141
Incident ID
Oil Conservation Division
Page 2
District RP
Facility ID
Application ID
Was this a major
If YES, for what reason(s) does the responsible party consider this a major release?
release as defined by
19.15.29.7(A) NMAC?
Yes
No
If YES, was immediate notice given to the OCD? By whom? To whom? When and by what means (phone, email, etc)?
Initial Response
The responsible party must undertake the following actions immediately unless they could create a safety hazard that would result in injury
The source of the release has been stopped.
The impacted area has been secured to protect human health and the environment.
Released materials have been contained via the use of berms or dikes, absorbent pads, or other containment devices.
All free liquids and recoverable materials have been removed and managed appropriately.
If all the actions described above have not been undertaken, explain why:
Per 19.15.29.8 B. (4) NMAC the responsible party may commence remediation immediately after discovery of a release. If remediation
has begun, please attach a narrative of actions to date. If remedial efforts have been successfully completed or if the release occurred
within a lined containment area (see 19.15.29.11(A)(5)(a) NMAC), please attach all information needed for closure evaluation.
I hereby certify that the information given above is true and complete to the best of my knowledge and understand that pursuant to OCD rules and
regulations all operators are required to report and/or file certain release notifications and perform corrective actions for releases which may endanger
public health or the environment. The acceptance of a C-141 report by the OCD does not relieve the operator of liability should their operations have
failed to adequately investigate and remediate contamination that pose a threat to groundwater, surface water, human health or the environment. In
addition, OCD acceptance of a C-141 report does not relieve the operator of responsibility for compliance with any other federal, state, or local laws
and/or regulations.
Printed Name: ___________________________________________
Title: ______________________________________________
Signature: ______________________________________________
Date: _____________
email: ________________________________________
Telephone: ______________________________
OCD Only
Received by: ___________________________________________
Date: _______________
State of New Mexico
Form C-141
Incident ID
Oil Conservation Division
Page 3
District RP
Facility ID
Application ID
Site Assessment/Characterization
This information must be provided to the appropriate district office no later than 90 days after the release discovery date.
What is the shallowest depth to groundwater beneath the area affected by the release?
(ft bgs)
Did this release impact groundwater or surface water?
Yes
No
Are the lateral extents of the release within 300 feet of a continuously flowing watercourse or any other significant
Yes
No
watercourse?
Are the lateral extents of the release within 200 feet of any lakebed, sinkhole, or playa lake (measured from the
Yes
No
ordinary high-water mark)?
Are the lateral extents of the release within 300 feet of an occupied permanent residence, school, hospital, institution,
Yes
No
or church?
Are the lateral extents of the release within 500 horizontal feet of a spring or a private domestic fresh water well used
Yes
No
by less than five households for domestic or stock watering purposes?
Are the lateral extents of the release within 1000 feet of any other fresh water well or spring?
Yes
No
Are the lateral extents of the release within incorporated municipal boundaries or within a defined municipal fresh
Yes
No
water well field?
Are the lateral extents of the release within 300 feet of a wetland?
Yes
No
Are the lateral extents of the release overlying a subsurface mine?
Yes
No
Are the lateral extents of the release overlying an unstable area such as karst geology?
Yes
No
Are the lateral extents of the release within a 100-year floodplain?
Yes
No
Did the release impact areas not on an exploration, development, production, or storage site?
Yes
No
Attach a comprehensive report (electronic submittals in .pdf format are preferred) demonstrating the lateral and vertical extents of soil
contamination associated with the release have been determined. Refer to 19.15.29.11 NMAC for specifics.
Characterization Report Checklist: Each of the following items must be included in the report.
Scaled site map showing impacted area, surface features, subsurface features, delineation points, and monitoring wells.
Field data
Data table of soil contaminant concentration data
Depth to water determination
Determination of water sources and significant watercourses within ½-mile of the lateral extents of the release
Boring or excavation logs
Photographs including date and GIS information
Topographic/Aerial maps
Laboratory data including chain of custody
If the site characterization report does not include completed efforts at remediation of the release, the report must include a proposed remediation
plan. That plan must include the estimated volume of material to be remediated, the proposed remediation technique, proposed sampling plan
and methods, anticipated timelines for beginning and completing the remediation. The closure criteria for a release are contained in Table 1 of
19.15.29.12 NMAC, however, use of the table is modified by site- and release-specific parameters.
State of New Mexico
Form C-141
Incident ID
Oil Conservation Division
Page 4
District RP
Facility ID
Application ID
I hereby certify that the information given above is true and complete to the best of my knowledge and understand that pursuant to OCD rules and
regulations all operators are required to report and/or file certain release notifications and perform corrective actions for releases which may endanger
public health or the environment. The acceptance of a C-141 report by the OCD does not relieve the operator of liability should their operations have
failed to adequately investigate and remediate contamination that pose a threat to groundwater, surface water, human health or the environment. In
addition, OCD acceptance of a C-141 report does not relieve the operator of responsibility for compliance with any other federal, state, or local laws
and/or regulations.
Printed Name: ___________________________________________ Title: ______________________________________________
Signature:______________________________________________ Date: _____________
email: ________________________________________
Telephone: _________________________________
OCD Only
Received by: ___________________________________________
Date: _________________
State of New Mexico
Form C-141
Incident ID
Oil Conservation Division
Page 5
District RP
Facility ID
Application ID
Remediation Plan
Remediation Plan Checklist: Each of the following items must be included in the plan.
Detailed description of proposed remediation technique
Scaled sitemap with GPS coordinates showing delineation points
Estimated volume of material to be remediated
Closure criteria is to Table 1 specifications subject to 19.15.29.12(C)(4) NMAC
Proposed schedule for remediation (note if remediation plan timeline is more than 90 days OCD approval is required)
Deferral Requests Only: Each of the following items must be confirmed as part of any request for deferral of remediation.
Contamination must be in areas immediately under or around production equipment where remediation could cause a major facility
deconstruction.
Extents of contamination must be fully delineated.
Contamination does not cause an imminent risk to human health, the environment, or groundwater.
I hereby certify that the information given above is true and complete to the best of my knowledge and understand that pursuant to OCD
rules and regulations all operators are required to report and/or file certain release notifications and perform corrective actions for releases
which may endanger public health or the environment. The acceptance of a C-141 report by the OCD does not relieve the operator of
liability should their operations have failed to adequately investigate and remediate contamination that pose a threat to groundwater,
surface water, human health or the environment. In addition, OCD acceptance of a C-141 report does not relieve the operator of
responsibility for compliance with any other federal, state, or local laws and/or regulations.
Printed Name: ___________________________________________ Title: ______________________________________________
Signature: _____________________________________________
Date: _____________
email: ________________________________________
Telephone: _________________________________
OCD Only
Received by: ___________________________________________ Date: _________________
Approved
Approved with Attached Conditions of Approval
Denied
Deferral Approved
Signature: ________________________________________
Date: _______________________
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