Application for Government Funding1.0 Project Details This section is completed by the applicant.

Bore rehabilitation works (GO TO ITEM 3)

Controlled water system works (piping works) (GO TO ITEM 4)

2.0 Department Certification This section is completed by the Department

1.1 Bore RN

1.2 Local bore name

1.3 Property bore is located on

1.4 Proposed works

2.1 Bore at item 1.1 drilled date

Indicate production casing material

Yes No

2.4 Is sufficient evidence provided to indicate that the bore identified at item 1.1 meets the minimum construction standards?

2.5 Total bore depth

2.7 High value spring within 50 km (name of spring group)

2.8 Pre-works flow rate and date (eg Source GWDB, external etc)

2.10 Estimated flow to be saved (ML/annum)

Yes No2.11 Stock route water requirment?

If yes, provide Stock Routes (State Land Asset Management) contact details below:

Full name

PhoneEmail

The Department certifies the information identified in Item 2.0.

Position Phone

Email

Full name

Signature Date

Yes No

Yes No

2.2 Located within corrosive area?

2.3 Critical infrastructure failure?

2.9 Licence bore drain condition? Yes No

Page of

Certification Statement

Both bore rehabilitation works and controlled water system works (piping works) (COMPLETE ALL SECTIONS EXCEPT ITEM 4)

2.6 GAB Management Area

Department of Natural Resources, Mines and Energy

FORM IGABIIP-001

3.0 Bore Rehabilitation Proposal This section completed by Class 3 driller Note: The Class 3 driller that certifies this Bore Rehabilitation Proposal, must also certify/inspect works upon completion.

If yes, specify dateYes No3.1 Has the bore been logged?

3.2 Proposed method of rehabilitation (eg. redrill and plug, reline)

Certification Statement

License number Expiry date

Entity name

Full name

ABN/ACN

Signature Date

Phone

Email

Postal address

I certify that the proposed bore rehabilitation works including materials, identified under item 3.0, meets the requirements of the "Minimum standards for the construction and reconditioning of water bores that intersect the sediments of artesian basins in Queensland", and that I will inspect these works upon completion.

3.3 Provide reasons as to why this method of rehabilitation was chosen (attach in Annexure 1 if more space is required)

Page of

GO TO ITEM 6 - BORE REHABILITATION PROPOSAL COSTING

4.0 Bore Works Proposal This section must be completed by a Class 3 driller or a Registered Professional Engineer of Queensland (RPEQ)

4.2 Provide details of works proposed to make bore meet minimum construction standards OR provide details of why the bore identified under item 1.1 is in a suitable condition for piping (attach in Annexure 1 if more space is required).

I certify that the bore identified at item 1.1 will not fail unexpectedly as a result of the installation of a controlled watering system, and is in a suitable condition for connecting to a controlled watering system as identified at item 4.0. (Class 3 driller or RPEQ can select this certification statement).

OR

I certify that the proposed bore works including materials, identified under item 4.0, meets the requirements of the 'Minimum standards for the construction and reconditioning of water bores that intersect the sediments of artesian basins in Queensland'. (Class 3 driller only can select this certification statement).

Please select one of the certification statements below

Phone

License/Registration number Expiry date

Entity name

Full name

ABN/ACN

Signature Date

Email

Postal address

4.1 Has the bore been logged? NoYes

Certification Statement

Page of

Note: The applicant must demonstrate the bore will not fail unexpectedly as a result of the installation of a controlled watering system.

This can be done by:

A) The applicant specifies work to be completed on the bore to bring it up to the minimum construction standard. This is to be certified by a Class 3 driller. All work to bring the bore up to the minimum construction standards is at the applicant's full expense. The driller is certifying that the proposed work and materials meet the requirements of the `Minimum standards for the construction and reconditioning of water bores that intersect the sediments of artesian basins in Queensland'.

OR,

C) A Class 3 driller / RPEQ certifying that the bore is in a suitable condition for connection to a controlled watering system.

If yes, specify date

GO TO ITEM 5 - CONTROLLED WATER SUPPLY WORKS PROPOSAL

5.2 Total water demand (L/day)

5.3 Total length of pipe to be installed

Certification Statement

Specify standard

b) The materials to be used have a 50 year design life, excluding tanks and troughing c) The tanks and/or troughing to be used have a 20 year design life

Registration number Expiry date

Entity name

Full name

ABN/ACN

Signature Date

Phone

Email

Postal address

5.0 Controlled watering system works proposal This section must be completed by a Registered Professional Engineer of Queensland (RPEQ).

Page of

5.1 Design drawings A map of the actual scheme to be installed must be attached to this submission. The map (or a combination of maps and supporting documentation) must be to scale and detail the following information: * north arrow * property and paddock boundaries, and paddock names * location of the bore * stock numbers per paddock used in the design * winter bore drain location/s * existing infrastructure (if applicable) * water point locations * air release and scour valve locations * cooling pond location (if applicable) * new infrastructure to be installed from the bore. These must be clearly distinguishable and tabulated separately detailing the following: - pipe pressure rating, length and sizes - tank sizes and quanities - trough sizes and quantities

I certify that the information identified in Item 5.0 is correct. a) The piping system has been designed and will be constructed in accordance with the Department's Guidelines (available on request), or will meet

GO TO ITEM 7 - WINTER BORE DRAIN

6.0 Bore rehabilitation proposal costing This section must be completed by the applicant.

6.2

6.3

6.1 Expenses (no asset extension expense to be included)

Page of

6.4

Materials - Site access (eg gravel) (Inc GST) $

Materials - Mandatory monitoring device (Inc GST) $

Drilling contractor (Inc GST) $

Pre-works flow testing (Inc GST) $

Geophysical logging and/or hydrogeological assessment (Inc GST) $

Telemetry infrastructure (Inc GST) $

Sub-Total (Inc GST) $

Applicant administration (5% or $5,500 Inc GST) $

Total (Inc GST) $

Proposed government funding (inc GST) (up to 90% of Item 6.2 above) $

% government funding to be disbursed to Stock Routes %

GO TO ITEM 7 - WINTER BORE DRAIN IF SUBMISSION INCLUDES CONTROLLED WATER SYSTEM WORKS OR GO TO ITEM 9 - GOVERNMENT VALUE FOR MONEY IF SUBMISSION IS REHABILITATION ONLY

9.0 Government value for money This section must be completed by the applicant.

Page of

GO TO ITEM 10 - APPLICANT CERTIFICATION

8.0 Controlled water system works proposal costing This section must be completed by the applicant.

8.1 Expenses (Bore drain area only)

GO TO ITEM 9 - GOVERNMENT VALUE FOR MONEY

GO TO ITEM 8 - CONTROLLED WATER SYSTEM WORKS PROPOSAL COSTING

7.2 Cap on subsidy (Item 7.1 * $6,090)

Survey Data must to be attached to this application7.1 Length (kms)

7.0 Winter Bore Drain This section must be completed by the applicant.

Materials - Tanks (inc GST) $

Materials - Troughs (inc GST) $

Materials - Pipe (inc GST) $

Materials - Fittings (inc GST) $

Materials - Cooling Grid (inc GST) $

Materials - Mandatory monitoring device (Inc GST) $

Subtotal (inc GST) $

Lesser of 7.2 and 8.2 $

Pre-works flow testing (inc GST) $

Installation $1,100/km (inc GST) $

Power Connection (inc GST) $

Engineer design & RPEQ Certification (inc GST) $

Telemetry infrastructure (inc GST) $

Subtotal (inc GST) $

Applicant administration (5% of item 8.3 above or $5,500 inc GST) $

Total (inc GST) $

Proposed government funding (up to 90% of Item 8.4 above) (inc GST) $

% of government funding to be disbursed to Stock Routes %

8.2

8.3

8.5

8.4

8.6

Formula to calculate: (Item 6.3 + Item 8.5) * 10 / 11 * Item 2.10 $

10.2 Stock Routes approval (completed by Stock Routes)

I certify that stock route requirements have been met by the proposed design and agree to the percentage of government funding to be disbursed to Stock Routes, outlined under Items 6.4 and/or 8.6.

Position

Phone

Email

Full name

Postal address

Signature Date

Mobile Fax

Certification Statement

Page of

Signature Date

Postal address

Email

Phone

ABN/ACN

Entity name

Full name

I certify that the information contained in this application form and the attachments is correct. My submission in this application: a) seeks the government funding for the amount identified in items 6.3 and/or 8.5, for

reimbursement to me following completion of the works specified b) meets my obligations under the 'Vegetation Management Act 1999' and the 'Cultural Heritage

Act 2003' c) meets the requirements of the 'Interim Great Artesian Basin Infrastructure Investment Program

Client Guidelines February 2018'

Certification Statement10.1 Applicant Certification10.0 Applicant

Certification This section must be completed by the applicant.

Position, if corporation

Page of

I acknowledge and agree that the applicant identified in Item 10.1: a) is authorised to act on my behalf with respect to works, identified in Item 1.0, that may affect

infrastructure carrying water within or to my property (my infrastructure); b) will under the Interim Great Artesian Basin Infrastructure Investment Program (the Program), receive

the total disbursement of the subsidy, even where part of the works affect my infrastructure. Further I acknowledge that the department has no obligation to pay any part of the subsidy or other amounts beyond the subsidy to either the applicant or myself.

I understand that: a) if I choose to undertake works affecting my infrastructure or my property and I incur costs that the

department is not liable to reimburse any part of these costs to me and that I will be responsible for seeking reimbursement from the applicant;

b) my undertaking of any of the works will not be considered participation for the purposes of the Program and does not guarantee me access to water from the bore, which is located on the applicant's land;

c) any arrangement for access to water from the bore on the applicant's property is a private arrangement between myself and the applicant;

d) unless my arrangement with the applicant for access to water is recorded on a binding agreement (water agreement) that the applicant may at any time withdraw its approval for me to access water from the bore and I understand that the department is unable to interfere with or enforce these private arrangements;

e) the department is not required to give its consent or approval to such private arrangements between myself and the applicant;

f) the department has recommended that I seek independent legal advice with respect to: - my undertaking the works over infrastructure affecting my infrastructure or my property; - the issue of access to and use of my infrastructure or the applicant's infrastructure,

including the bore, and the requirement for a legally binding and suitable water agreement to meet our respective needs;

- the statements within this application and the effect of the Program generally. g) the department is unable to discuss the progress of this application, the works or the disbursement of

the subsidy with me without the prior written consent of the applicant. h) the department is relying upon the information in this certification statement; and i) nothing contained in this application will be taken as giving rise to any employment, agency,

partnership or joint venture relationship between either the applicant, the department or myself

Certification Statement

10.3 Approval of all landholders (other than the applicant) currently watered by the bore listed in Item 1.0.

10.0 Applicant Certification

(continued)

This section must be completed by the applicant and any landholders that may be affected by the works and/or where the bore waters multiple properties.

Name of Property Watered Landholders' Name Signature of

Landholder Date

Annexure 1 includes: - Survey Data - Any additional information

Page of

ANNEXURE 1