Citizen Survey and Complaint Form

for Oil and Gas Industrial Noise Problems



Problem:  Excessive noise associated with oil and natural gas extraction activities. 


Purpose:  This form has been created to gather citizen complaints and bring them to the proper agencies and to push for  action to address noise problems.



1.       Is noise related to oil and gas extraction a problem for you and/or other family members?  __Yes           __No


If yes, please answer the following questions.


2.       Approximately how long has the noise(s) been a nuisance?   ______________ month(s) / year(s)


3.       Location of equipment or compressor(s) producing noise if known: (well site number/ company name) ________________________________________________________________________________________________________


4.       Please indicate level of the noise below:  Rate frequency of occurrence using #1 for never, through #5 for continuous


__ Compressor noise is not a nuisance at all

__ barely

__ Moderately loud

__ Uncomfortably loud

__ Intolerable


5. Does the noise interfere with sleep?  __Yes             __No


6. Do you know whom to call for noise or other gas and oil industry complaints?  __Yes    __No

    Please list contact:   _______________________________________________________________


7. Have you attempted to address a noise problem relating to oil and gas activities near your residence?  __ Yes  __No


    If yes, please describe and indicate whether or not your attempt resolved the noise problem.



8. Are you interested in participating in an effort to resolve noise problems with oil and gas extraction? If so, please provide       contact information here:


Name/Address                     ___________________________________________________________________________________


Phone:                   _____________________________________     Email:   __________________________________________



Thank you for taking the time to participate in this survey

Should you wish to write additional comments, use the backside of this paper and/or use additional paper as needed.


9. Can you be contacted for additional information or questions?     __Yes __ No