IEE Form Underground Water

Initial Environmental Examination (IEE) Form for Groundwater Abstraction Projects -2018
Note 1: In accordance with section 47 of the Regulation for Environmental Clearance of Projects 2016,
consent must be obtained from individual or juristic person if activity has direct impact on a
property.
Note 2: The completed IEE form shall be submitted to the relevant Competent Authority.
Note 3: The completed IEE form shall be the basis to determine the requirement of Environmental Impact
Assessment (EIA). If EIA is required, applicant will be notified to submit Terms of Reference for
the project.
Note 4: The application shall be subjected to Fee Schedules to cover the cost of administering the
Environmental Assessment Act, 2000.
1.
General Information:
a) Name of the project:………………………………………
b) Project Type (Tick as appropriate): ☐ New ☐ Expansion/modification
c) Applicant Details
I. Name of the applicant:…………………

II. Address:…………………………………
III. Post Box No.:……………………………
IV. Contact No.:……………………………..
V. Fax No.:…………………………………
VI. Email:……………………………………
VII. Name and contact details of Environmental Focal Person:………………
2. Project Location:
I. Dzongkhag/Thromde: ……………………
II. Gewog:……………………………………
III. Village:……………………………………
IV. Name of the project site:…………………..
3. Project Cost (Nu.):………………………………
4. Project area, tick as appropriate:

a) ☐ Industrial Area……………….acres
b) ☐ Industrial Estate……………...acres
c) ☐ State Reserve Forest………..acres
d) ☐ Private………………………acres
e) ☐ Others……………………….acres
f) Total area required……………..acres
Note: If the activity is proposed in industrial area /estate, skip sections 5 and 6
5. Terrain characteristic at the project site:
a) Elevation –meter:……….
b) Land form:
 ☐ Flood plain:………..
 ☐ Alluvial deposit:…………...
 ☐ Colluvial deposit:………….
 ☐ Others:…………….
6. Presence of any of the following within and 50 meters buffer of the project area. If yes tick and mention name, wherever
applicable:
a) ☐ Rivers/springs/streams/wells/lakes…………………..
b) ☐ Agriculture land…………………………………………
c) ☐ Heritage site……………………………………………
d) ☐ Hospital………………………………………………....
e) ☐ School/institution………………………………………
f) ☐ Roads……………………………………………………
g) ☐ Industries………………………………………………..
h) ☐ Settlements……………………………………………..
i) ☐ Religious site………………………………
j) ☐ Archaeological site……………………………………
k) ☐ Others
7. Project Details (attached in a separate sheet):
a) Project objective:…………………………………………
b) Project output:……………………………………………
c) Total requirement –cubic meter/day:…………
d) Installed capacity of the bore-well:………………….
e) Geo-coordinates of the proposed site:………………
f) Width and depth of the bore-well –meters:………….
g) Depth of water-table in meters:
 ☐ December:……………………………..
 ☐ January:………………………………..
 ☐ February:……………………………….
h) Source of energy, tick as appropriate:
 ☐ Electricity, if yes, Tapping point:……………………
 ☐ Solar
 ☐ Wind
 ☐ Others
i) Parameters of groundwater:
 ☐ pH:……………………..
 ☐ Turbidity (NTU):……………........
 ☐ Conductivity (μS/cm):………..

8. Ancillary activities, tick as appropriate:
a) ☐ Power line
b) ☐ Approach road
c) ☐ Others
Note: For ancillary activities, fill up relevant IEE forms and submit along with these IEE forms.
9. List type of wastes under each category and its quantity per annum, tick as appropriate:
a) ☐ Solid:………………………………
b) ☐ Liquid/effluent:……………………
c) ☐ Air/Gaseous:………………………
10. Provide maximum noise level at the project boundary during operation, if applicable:
11. Environmental Management Plan (attached in a separate sheet):

Briefly describe mitigation measures to address impacts including sections 9 and 10
12. Environmental Management Plan (attached in a separate sheet): Briefly describe mitigation measures to address impacts
including sections 9 and 10.
Environment Management Plan/EMP
Name of work:
Sl. No Activities Potential Negative impact Proposed Mitigation Responsible Agency

measures with costing
Implementatio Monitoring
n
2
3
13. List of documents to be attached with this IEE form:
1 Public consultation records verified by the concerned local authority
2 Layout plan and KMZ file depicting entire layout plan
3 Revenue Receipt copy_Fee Payment
Note: If the activity is proposed in the industrial area/estate, list of document from 1 to 3 are not required.
Name and signature of the project proponent:

Address:
Date:

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Initial Environmental Examination (IEE) Form for Groundwater Abstraction Projects -2018

a) Name of the project:………………………………………

b) Project Type (Tick as appropriate): ☐ New ☐ Expansion/modification

I. Name of the applicant:…………………

4. Project area, tick as appropriate:

5. Terrain characteristic at the project site:

11. Environmental Management Plan (attached in a separate sheet):

Environment Management Plan/EMP

Sl. No Activities Potential Negative impact Proposed Mitigation Responsible Agency

13. List of documents to be attached with this IEE form:

1 Public consultation records verified by the concerned local authority

2 Layout plan and KMZ file depicting entire layout plan

3 Revenue Receipt copy_Fee Payment

Name and signature of the project proponent:

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