Please fill in the following form as completely as possible. Providing as much detail as possible will assist us in helping you quickly.
Name of Your Organization or Municipality:
When was your group formed? Approx. Membership:
Name/Title of Contact Person:
Address:
Email:
What stream or watershed area requires the technical assistance (watershed, county or counties, townships, or other geographical description of your area)?:
1. What kind(s) of technical assistance do you require (check all that apply and describe on below)?
Rapid Characterization of Mine Drainage (a review of existing data and a one-day field visit resulting in a short report of findings and recommendations) Rapid Watershed Snapshot / Assessment Conceptual Design of Passive Treatment System Construction Oversight of Passive Treatment System Existing Passive Treatment System Evaulation and Recommendations Empowering Your Group to Address AMD Other Mine Drainage Assistance:
Description of technical assistance above:
2. What information on your watershed already exists (check all that apply)?
Stream Restoration/Management Plan Rivers Conservation Plan Project Scarlift Report TMDL Study Other Reports describing mine discharges or the watershed (describe here) Water Quality Data (please describe type and condition of data here) GIS mapping Other:
3. Has your group ever received a Growing Greener , 319 Program, WAG or Source Water Protection Grant?
No Yes **List Grants here
4. Are you requesting technical assistance to complete or improve a project that has already been funded?
No Yes **If yes, indicate funding source
5. Are you requesting technical assistance that is necessary to implement recommendations in your watershed restoration plan, protection plan or Rivers Conservation Plan?
No Yes **If yes, what is the name of the plan
6. Are you requesting technical assistance that must be completed in order for your group to apply for other grant funds?
No Yes If yes, name funding source:
Funding Application Deadline Date:
(Please describe the project you will be applying for below.)
7. Will your group be able to provide monetary matching or in-kind assistance (for instance, assist with watershed sampling, gathering existing info rmation, etc)?
No Yes **If Yes, Describe:
Please provide additional comments below (indicate question number from above if applicable) :
If you would like to send additional documents, you can do so by emailing Amy Wolfe at awolfe@tu.org