JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Landowner's Impact Form - Protecting Critical Property Features of Monroe County Landowners
Thank you for helping to protect your property and Monroe County. The following questions cover areas that the Federal Energy Regulatory Commission looks at when it considers “environmental impact.” They identify issues that need attention before routing a pipeline on or near your property. Not all will apply to you. Please add comments in the areas provided, or at the end.
All property-related information you share is voluntary, optional and confidential.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
I give my permission for the Indian Creek Watershed Association to share my information with the Federal Energy Regulatory Commission and/or the US Forest Service for the purpose of protecting important aspects of my property.
Yes
No
Clear selection
I give permission for the Indian Creek Watershed Association to collect and share a summary of this information for the purpose of protecting important aspects of Monroe County. The summary will not include identifiable personal or property information.
Yes
No
Clear selection
I would consider giving permission to the Federal Energy Regulatory Commission to conduct an environmental survey of my property as part of its environmental impact assessment of the proposed MVP route.
Yes
No
Clear selection
PROPERTY OWNER INFORMATION
Last Name(s) Property Owner
*
Your answer
First Name(s) Property Owner
*
e.g., Betty, or James and Clara
Your answer
E-mail address
*
If you do not have e-mail, write "none" in the space below.
Your answer
Mailing Address - PO Box or Street Address
*
Your answer
Town
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Phone Number
*
Number where you would like us to contact you if we have any questions
Your answer
PROPERTY IDENTIFICATION INFORMATION
Property Owner(s)
*
Your answer
Physical Address (911 address, if known)
*
Your answer
Location of property
Describe directions to property: i.e., Ellison Ridge Rd, approx. 2 mi. from Hans Cr. Rd. on left
Your answer
Is your property located on or near one of the pipeline routes?
Select one
On MVP Proposed Corridor - October 2014
Near MVP Proposed Corridor - October 2014
On MVP Alternate Rte 110 - February 2015
Near MVP Alternate Rte 110 - February 2015
In Monroe County but not on or near proposed pipeline routes
Clear selection
How long have you owned and/or resided on this property?
Your answer
How long has this property been in your family?
Your answer
Are there things that especially stand out in your mind regarding your property?
Your answer
WATER USE AND QUALITY
What watershed is your property located in? Check one.
Second Creek (to Greenbrier R.)
Wolf Creek (to Greenbrier R.)
Indian Creek (to New R.)
Rich Creek (to New R.)
Cove Creek / Sweet Springs Creek (to Dunlap Cr.)
Potts Creek (to Jackson R.)
Don't know / Other Option 1
Clear selection
What is your drinking water source? Check all that apply.
Yes
No
spring
well
cistern
public water (town or PSD)
bottled water
Yes
No
spring
well
cistern
public water (town or PSD)
bottled water
Clear selection
What is your primary source for drinking water?
If public water, please include your public service district (Union, Red Sulphur PSD ...)
Your answer
Depth of well (if applicable)
Your answer
If you have a well, spring, or cistern, have you had your water tested within the last 5 years?
Yes
No
Clear selection
I would like information about getting my water tested
Yes
No
Clear selection
Additional information about quality/quantity of your water
Your answer
Distance of water source(s) from proposed pipeline in feet (approximately)
Your answer
Other water features of your property. Check all that apply.
Yes
No
Pond
Year-round stream
Seasonal stream
Streams that disappear underground
Year-round spring
Seasonal spring
Other
Yes
No
Pond
Year-round stream
Seasonal stream
Streams that disappear underground
Year-round spring
Seasonal spring
Other
Clear selection
Number of springs and other water feature information or comments (optional)
Your answer
Other uses of water on your property?
Yes
No
Watering livestock
Irrigating crops or gardens
Fishing
Stocked fish ponds
Other
Yes
No
Watering livestock
Irrigating crops or gardens
Fishing
Stocked fish ponds
Other
Clear selection
Other water usage information or comments (optional)
Your answer
GEOLOGY/SOILS
Does your property have any of the following geology or soil features?
Yes
No
Don't know
Steep slopes subject to erosion (enter % below)
Agricultural land subject to compaction and mixing if disturbed (enter # acres below)
Sinkhole or surface openings
Caves
Rock outcropping
Floodplain
Fossils
Yes
No
Don't know
Steep slopes subject to erosion (enter % below)
Agricultural land subject to compaction and mixing if disturbed (enter # acres below)
Sinkhole or surface openings
Caves
Rock outcropping
Floodplain
Fossils
Clear selection
% steep slope and/or # acres agricultural land (if known)
Your answer
Other geological/soil information or comments (optional)
Your answer
CULTURAL/HISTORICAL FEATURES
Does your property have any of the following cultural/historical features?
Yes
No
Don't know
Native American artifacts/sites (arrowheads, burial grounds, etc.)
Known historic events (battles, trails)
Early settler or Civil War artifacts (musketballs, etc.)
Old buildings/schools/churches/ forts/foundations/homesites
Cemeteries/graves
Old orchards (legacy or heirloom)
Old roads or trails
Recreational trails
Yes
No
Don't know
Native American artifacts/sites (arrowheads, burial grounds, etc.)
Known historic events (battles, trails)
Early settler or Civil War artifacts (musketballs, etc.)
Old buildings/schools/churches/ forts/foundations/homesites
Cemeteries/graves
Old orchards (legacy or heirloom)
Old roads or trails
Recreational trails
Clear selection
Please describe these features (optional)
(e.g., I have a family cemetery on or near my property; part of my great-grandfather's house is still standing)
Your answer
LAND USE, RECREATION, AESTHETICS
Would any of the following features of your property be affected by the pipeline?
Yes
No
Trails that you use for recreation
Ponds or streams for recreational use
"Special" places for family or friend events (e.g., reunions, socializing, holidays, camping)
Special views that you see FROM your property
Special views that the public sees OF your property
Yes
No
Trails that you use for recreation
Ponds or streams for recreational use
"Special" places for family or friend events (e.g., reunions, socializing, holidays, camping)
Special views that you see FROM your property
Special views that the public sees OF your property
Clear selection
If you have special views that you enjoy FROM your property, please describe.
Your answer
If there are special views OF your property, please describe.
Your answer
As you drive through Monroe County, how important is the unbroken presence of Peters Mountain to you?
not important
1
2
3
4
5
very important
Clear selection
As you drive through Monroe County, how important are the unspoiled views of the hills and farmland to you?
not important
1
2
3
4
5
very important
Clear selection
Other land use, recreation, aesthetics information or comments (optional)
Your answer
WILDLIFE, FISHERIES, VEGETATION, SPECIAL STATUS
Do you have any of the following on your property?
Yes
No
Don't know
Threatened or endangered plant species
Migratory birds
Migratory insects
Threatened or endangered animals and/or habitat
Fish habitat (spawning)
Wetlands, marshes, bogs
Riparian buffer zones
Unusual plants or large trees
Eagle or other nests
Yes
No
Don't know
Threatened or endangered plant species
Migratory birds
Migratory insects
Threatened or endangered animals and/or habitat
Fish habitat (spawning)
Wetlands, marshes, bogs
Riparian buffer zones
Unusual plants or large trees
Eagle or other nests
Clear selection
Unusual or endangered species present (optional)
Your answer
SOCIO-ECONOMIC
Do you use your property in any of the following ways?
Yes
No
I operate a farm business on my property
I operate a non-farm business
I have marketable timber
I raise garden vegetables
I raise farm animals for my family's use
I raise bees
I cut firewood on this property
Yes
No
I operate a farm business on my property
I operate a non-farm business
I have marketable timber
I raise garden vegetables
I raise farm animals for my family's use
I raise bees
I cut firewood on this property
Clear selection
Additional comments about how you use (or plan to use) your land
(e.g., Is your business for primary income or supplemental? Do you raise vegetables or bees for personal use or supplemental income? Do you have projects planned that could be impacted?)
Your answer
We rely on the food we raise to live within our means.
How much do you agree with this statement?
strongly disagree
1
2
3
4
5
strongly agree
Clear selection
Raising our own food is important to us.
How much do you agree with this statement?
strongly disagree
1
2
3
4
5
strongly agree
Clear selection
When someone needs help, we rely on family and friends more than hiring someone.
How much do you agree with this statement?
strongly disagree
1
2
3
4
5
strongly agree
Clear selection
We are counting on our property value or our property use for our future economic well-being.
How much do you agree with this statement?
strongly disagree
1
2
3
4
5
strongly agree
Clear selection
I am concerned that pipeline construction and maintenance will block my road for access to town or for emergency vehicles in the case of fire, accidents, or medical emergencies.
How much do you agree with this statement?
strongly disagree
1
2
3
4
5
strongly agree
Clear selection
Other uses of your property that might be impacted by the pipeline (optional)
Your answer
AIR QUALITY AND NOISE: HEALTH-RELATED ISSUES
I am concerned that someone in my household will be harmed by air pollution or noise associated with pipeline construction and maintenance.
yes
no
Clear selection
Other air quality and noise comment (optional)
Please do not provide specific health/medical information.
Your answer
STATE OR FEDERAL CONSERVATION PROGRAMS
Do you participate in any federal or state conservation programs?
(e.g., NRCS, FSA, USDA, Conservation Reserve Program, State Conservation Agency, cost-share)
Yes
No
Clear selection
Has any program placed a restriction on the use of your property?
(e.g., conservation easement, riparian buffer zones, ponds or water systems, plantings for wildlife, tree planting)
Yes
No
Clear selection
Other information about state or federal programs (optional)
Your answer
PERSONAL CONNECTION TO YOUR PROPERTY
Choose the statement that is closest to your own experience.
Choose one
I have lived here all (or most) of my life.
I moved away from here but came back to live.
I live here now but moved from someplace else.
I bought this property for hunting and/or vacations.
I bought this property and plan to live here someday.
Clear selection
Why have you chosen this property in Monroe County?
Your answer
Do you value your property more as a real estate investment or a place you want to live?
Choose one
A real estate investment
A place I want to live
Clear selection
How important to you is the history of your property or community?
(e.g., family history, memories, old stories)
not important
1
2
3
4
5
very important
Clear selection
Work-related questions:
Please answer based on if you (or your spouse) traveled a long distance to work, either now or in the past. Choose all that apply.
I live here even though I have to (or used to) travel long distances to get to work.
I would rather live here than move someplace closer to better-paying jobs.
Does not apply
What is the longest distance you have driven to work from your property in Monroe County? (if applicable)
Your answer
My personal history and identity are closely tied to this land.
How much do you agree with this statement?
strongly disagree
1
2
3
4
5
strongly agree
Clear selection
I feel more myself on my property than anywhere else.
How much do you agree with this statement?
strongly disagree
1
2
3
4
5
strongly agree
Clear selection
Closing Comment (optional)
Please feel free to add anything else you would like to share.
Your answer
Important: Print before submitting to review or save a printed copy.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
