DMR Forms

Overview

Below is a list of forms used by the Division of Mining and Reclamation. Only those forms which are not available on the ePermitting system are listed here. If you have any questions regarding a specific form please contact the DMR.

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See Also

Contact Us

West Virginia Department of Environmental Protection
Division of Mining and Reclamation
601 57th Street SE
Charleston, WV 25304
Phone: (304) 926-0490
Fax: (304) 926-0456
Additonal DMR Contacts


MR-4C: Incidental Coal Removal for Construction

Revised: August, 2007
General Permit/Special Authorization for Construction Activities with Incidental Coal Removal


MR-27: Request for Endangered Species Consultation


MR-30: Small Operator Assistance Program

Revised: December, 2002


MR-SHPO: State Historic Preservation Questionnaire

Revised: September, 2006
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. 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.

Blasting Fee Affidavit

Revised: April, 2017
Failure to comply with the fee requirements of W.Va. Code §22-3 and 199CSR1 by the due date may result in permit suspension or revocation in accordance with W.Va. Code §22-3-17.


EB-37: Blast Log

Revised: November, 2019
The blast log must be completed within 24 hours of the shot. If there are any unusual events associated with the blast, the log must be completed that day by the blaster-in-charge before leaving the mine site. A shot number should be used to consecutively number each blast for a permit.


EB-38: Blast Ad

Revised: April, 2017
Public notice of blasting operations.


EB-39: Blast Notification

Revised: March, 2017
Sample notification letter for pre-blast surveys. The law requires that you offer a pre-blast survey to every resident and owner of a building within the pre-blast survey radius for this mine permit. The pre-blast survey will record and document the physical condition of the dwelling or structure prior to blasting on this permit.


EB-40: Pre-Blast Survey

Revised: April, 2017
All pre-blast surveys must include the Pre-Blast Survey Form (EB-40), Request for Pre-blast Survey Form if available (EB-39A), map that identifies the structure, and a letter from insurance company authorizing the surveying company to do the pre-blast survey. All surveys must include an owner's name. Tax records from the courthouse will provide a name of the individual paying taxes on the structure. Surveys will be compared with Section T of the Surface Mine Application to verify that all structures have a pre-blast survey, waiver or affidavit.


EB-41: Pre-Blast Survey Inventory Form

Revised: April, 2017
This form (hard copy) must be completed and submitted to the Division of Mining and Reclamation with each batch of surveys.

Option to Invest / W-9

Revised: December, 2012
Cash performance bonds posted with the West Virginia Department of Environmental Protection pursuant to Chapter 22 of the Code of West Virginia are eligible for investment in the West Virginia Consolidated Fund, with interest payable to the operator posting the bond. Under the provisions of W.Va. Code §12-6-8 and §12-6C-6, State agencies may request the West Virginia State Treasurer to invest funds administered by them.


MR-26: Annual Bonding Progress Report

Revised: September, 2006
Complete this form and attach Annual Bonding Progress Report Map and any necessary additional bond in the proper form. Mail one original and three copies of this application, each in a separate binder, to the Permitting Section of the Regional WV DEP Mining and Reclamation Office. Application must be received at least 30 days prior to the anniversary date of the permit. If the Annual Bonding Progress Report Map from the previous year remains accurate, a new map is not required. However, the bonding chart below must be completed.


Certificate of Deposit Waiver

Bank waiver for Certificates of Deposit.


Letter of​ Credit

The following letter of credit has been prescribed by the Secretary of the Department of Environmental Protection and approved by the State Attorney General's Office for use as a performance bond for mining permits. This format is to be retyped on letterhead of the bank issuing the Letter of Credit filling in the blanks where required. No changes may be made to this language without the prior approval of the Secretary and the Attorney General.


Letter of Assignment for Certificate of Deposit

Letter of assignment template for assigning the right to endore a Certificate of Deposit to DEP in the event of permit revocation.


Mitigation Surety Bond

Revised: November, 2007
Template for mitigation surety bond.


Reclamation Surety Bond

Revised: June, 2005
Template for reclamation surety bond.


Self Bond Application

Revised: March, 1998
To qualify for self-bonding, a coal operator's/guarantor's proposed and outstanding self-bonds may not exceed 25% of the operator's guarantor's tangible net worth in the United States.


Transfer of Performance Bond

Revised: March, 2022
Template form to transfer a performance bond.

MR-42: Combining Querry Permits

Revised: September, 2006
Checklist for combining quarry permits.


MR-43: Groundwater Questionnaire-Quarry

Revised: September, 2006
Groundwater inventory questionnaire.


MR-45: HazMat Evaluation and Inventory

Revised: September, 2006
Hazardous materials evaluation and inventory checklist.


MR-19CK: Operator Assignment/Transfer Assignment or Sale Checklist

Revised: July, 2017
Checklist for MR19 and MR19A.


MR-46: Roads and Ancillary Facilities Checklist


MR-13: Certification of Drainage System

Revised: December, 2006
Certification that the controls meet the required safety factor and is/are constructed and installed in accordance with the technical aspects of the pre-plan and any modification thereto, as approved by the Department of Environmental Protection.


MR-50: Approved Persons

Revised: September, 2006
Application for approved person for surface coal mine and quarry permits.


MR-23: Progress Map Reporting

Revised:
Progress map reporting form.


MR-29: Certification of Operations Designed Using Final AOC Guidance Document

Revised: August, 2001
For steep slope operations only.

MR-34-B: NPDES Advertisements

Revised: August, 2005
NPDES issuance/reissuance advertisement.


MR-5 NPDES/Article 11 Water Pollution Control Permit

Revised: June, 2004
NPDES/Article 11 Water Pollution Control Permit MR-5 Application, General Instructions


MR-19A-CK: Checklist for NPDES Transfer and Advanced Approval


Additional Resources

Reissuance Non-Slurry Application

Revised: March, 2019
Class 5, Type 5X13/Type 5G30 Underground Injection Control (UIC) Reissuance Application For Coal Mines Non-Slurry Injection
The purpose of this UIC reissuance application is to gather detailed and technical information the WVDEP and the Division of Mining and Reclamation requires to make sound permitting decisions, within the regulatory framework of West Virginia Code of State Regulations and all other applicable state and federal mining regulations.


New Non-Slurry Application

Revised: August, 2018
Class 5, Type 5X13/Type 5G30 Underground Injection Control (UIC) New Permit Application For Coal Mines Non-Slurry Injection
The purpose of this UIC reissuance application is to gather detailed and technical information the WVDEP and the Division of Mining and Reclamation requires to make sound permitting decisions, within the regulatory framework of West Virginia Code of State Regulations and all other applicable state and federal mining regulations.


5G30 Mine Water Transfer Application

Revised: September, 2018
Class 5, Type 5G30 Underground Injection Control (UIC) Mine Water Transfer Permit Application For Coal Mines and Quarries
The purpose of this UIC permit application is to gather sufficient information to review the “Mine Water Transfer” proposal. This activity involves transferring mine water, by either pumping or gravity flow, from a mine void to the surface, transporting it across the surface via piping, and injecting it back into a mine void via a certified Class 5, Type 5G30 injection well, without treatment or processing of the mine water.


UIC Annual Report

Revised: November, 2018
Reporting form for total volume injected, min/max mine pool levels, injection points, modifications to existing UIC control permits, and injection volume details.


Permit Application for Slurry Injection

Revised: July, 2019
Class 5, Type 5X13 Underground Injection Control (UIC) Permit Application for Coal Mines Slurry Injection
The purpose of this UIC reissuance application is to gather detailed and technical information the WVDEP and the Division of Mining and Reclamation requires to make sound permitting decisions, within the regulatory framework of West Virginia Code of State Regulations and all other applicable state and federal mining regulations.


Modification Application

Revised: February, 2020
Class 5, Type 5X13 Underground Injection Control (UIC) Modification Application for Coal Mines Slurry Injection
The purpose of this UIC reissuance application is to gather detailed and technical information the WVDEP and the Division of Mining and Reclamation requires to make sound permitting decisions, within the regulatory framework of West Virginia Code of State Regulations and all other applicable state and federal mining regulations.


Transfer Application

Revised: February, 2022
Class 5, Type 5X13 Underground Injection Control (UIC) Permit Transfer Application for Coal Mines Slurry Injection


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