WEST VIRGINIA LAND STEWARDSHIP CORPORATION
CONSULTANT QUALIFICATION QUESTIONNAIRE
Project Name
Statewide Engineering Services
Date
Click or tap to enter a date.
FEIN Number
Click or tap here to enter text.
1. Firm Name
Click or tap here to enter text.
2. Address
Click or tap here to enter text.
3. Former Firm Name, if any
Click or tap here to enter text.
4. Contact Name and Telephone
Click or tap here to enter text.
5. Year Established
6A. Is the firm a WV Registered DBE
(Disadvantaged Business Enterprise)?
6. Ownership Structure
☐Individual
☐Corporation
☐Partnership
☐Joint Venture
☐Yes
☐No
7A. Name, Title, & Telephone – Other Principals
Click or tap here to enter text.
7. Principal Officers or Members of Firm
Click or tap here to enter text.
8. Number of Personnel by Discipline:
#
Discipline
Administrative
Architects
Biologists
CADD Operators
Chemical Engineers
Civil Engineers
Construction Inspectors
Designers
Draftsmen
Ecologists
#
Discipline
Economists
Electrical Engineers
Environmentalists
Estimators
Geologists
Historians
Hydrologists
Landscape Architects
Mechanical Engineers
Mining Engineers
#
Discipline
Planners: Urban Regional
Photogrammetrists
Sanitary Engineers
Soils Engineers
Specification Writers
Surveyors
Structural Engineers
Traffic Engineers
Other
Total Personnel
8A. Total Number of WV Registered Professional Engineers in Primary Office:
*RPEs other than Civil and Mining must provide supporting documentation that qualifies them to supervise and perform this type of work.
1
9. If this is a joint-venture, has this joint-venture worked together before? ☐Yes
☐ No
10. List outside key consultants/sub-consultants anticipated to be used. (Attach “Consultant Qualification Questionnaire” for each)
Name and Address:
Click or tap here to enter text.
Specialty:
Click or tap
here to enter
text.
Worked with before?
☐ Yes
☐ No
Name and Address:
Click or tap here to enter text.
Specialty:
Click or tap
here to enter
text.
Worked with before?
☐ Yes
☐ No
Name and Address:
Click or tap here to enter text.
Specialty:
Click or tap
here to enter
text.
Worked with before?
☐ Yes
☐ No
Name and Address:
Click or tap here to enter text.
Specialty:
Click or tap
here to enter
text.
Worked with before?
☐ Yes
☐ No
Name and Address:
Click or tap here to enter text.
Specialty:
Click or tap
here to enter
text.
Worked with before?
☐ Yes
☐ No
Name and Address:
Click or tap here to enter text.
Specialty:
Click or tap
here to enter
text.
Worked with before?
☐ Yes
☐ No
2
11.
A.
Does your firm have experience in designing passive treatment systems for Acid Mine Drainage (AMD) on bond forfeiture sites?
☐Yes
☐ No
If yes, please provide up to three projects your firm has designed and briefly describe each project including type(s) of treatment.
1. Click or tap here to enter text.
2. Click or tap here to enter text.
3. Click or tap here to enter text.
B.
Does your firm have experience in designing active treatment systems for AMD on bond forfeiture sites?
☐Yes
☐ No
If yes, please provide up to three projects your firm has designed and briefly describe each project including type(s) of treatment.
1. Click or tap here to enter text.
2. Click or tap here to enter text.
3. Click or tap here to enter text.
C.
Does your firm have experience completing an Acid Base Analysis (ABA) based on information generate by soil and refuse analytical
information on bond forfeiture sites?
☐Yes
☐ No
If yes, please provide up to three projects your firm has designed and briefly describe each project including type(s) of treatment.
1. Click or tap here to enter text.
2. Click or tap here to enter text.
3. Click or tap here to enter text.
3
D.
Does your firm have experience in using hydrological and hydraulic engineering principals in designing collection and transporting systems
for AMD and surface water on bond forfeiture sites?
☐Yes
☐ No
If yes, please provide up to three projects your firm has designed and briefly describe each project including type(s) of treatment.
1. Click or tap here to enter text.
2. Click or tap here to enter text.
3. Click or tap here to enter text.
E.
Does your firm have experience in designing land reclamation projects of bond forfeiture sites inclusive of but not limited to highwall
reclamation, site grading, revegetation, material placement planning, pond reclamation, and road reclamation?
☐Yes
☐ No
If yes, please provide up to three projects your firm has designed and briefly describe each project including type(s) of treatment.
1. Click or tap here to enter text.
2. Click or tap here to enter text.
3. Click or tap here to enter text.
F.
Does your firm have experience in inspecting mine reclamation construction projects?
☐Yes
☐ No
If yes, please provide up to three projects your firm has designed and briefly describe each project including type(s) of treatment.
1. Click or tap here to enter text.
2. Click or tap here to enter text.
3. Click or tap here to enter text.
4
G.
A. Explain in detail how your firm is committed to meeting project deadlines.
Click or tap here to enter text.
B. What measures are in place at your firm to assure project deadlines are met?
Click or tap here to enter text.
12A. Personal History Statement of Principals & Associates Responsible for Project Design (Furnish complete information but keep to essentials)
Name & Title
Click or tap here to enter text.
YEARS OF EXPERIENCE
Years of AMD Related Design Experience
Brief explanation of responsibilities:
Click or tap here to enter text.
Education (Degree, year, specialization)
Click or tap here to enter text.
Membership in Professional Organizations
Registration (Type, year, state)
Click or tap here to enter text.
Click or tap here to enter text.
5
12B. Personal History Statement of Principals & Associates Responsible for Project Design (Furnish complete information but keep to essentials)
Name & Title
Click or tap here to enter text.
YEARS OF EXPERIENCE
Years of AMD Related Design Experience
Brief explanation of responsibilities:
Click or tap here to enter text.
Education (Degree, year, specialization)
Click or tap here to enter text.
Membership in Professional Organizations
Registration (Type, year, state)
Click or tap here to enter text.
Click or tap here to enter text.
12C. Personal History Statement of Principals & Associates Responsible for Project Design (Furnish complete information but keep to essentials)
Name & Title
Click or tap here to enter text.
YEARS OF EXPERIENCE
Years of AMD Related Design Experience
Brief explanation of responsibilities:
Click or tap here to enter text.
Education (Degree, year, specialization)
Click or tap here to enter text.
Membership in Professional Organizations
Registration (Type, year, state)
Click or tap here to enter text.
Click or tap here to enter text.
6
12D. Personal History Statement of Principals & Associates Responsible for Project Design (Furnish complete information but keep to essentials)
Name & Title
Click or tap here to enter text.
YEARS OF EXPERIENCE
Years of AMD Related Design Experience
Brief explanation of responsibilities:
Click or tap here to enter text.
Education (Degree, year, specialization)
Click or tap here to enter text.
Membership in Professional Organizations
Registration (Type, year, state)
Click or tap here to enter text.
Click or tap here to enter text.
12E. Personal History Statement of Principals & Associates Responsible for Project Design (Furnish complete information but keep to essentials)
Name & Title
Click or tap here to enter text.
YEARS OF EXPERIENCE
Years of AMD Related Design Experience
Brief explanation of responsibilities:
Click or tap here to enter text.
Education (Degree, year, specialization)
Click or tap here to enter text.
Membership in Professional Organizations
Registration (Type, year, state)
Click or tap here to enter text.
Click or tap here to enter text.
7
13. Provide a list of software and equipment available in the PRIMARY office which will be used to complete design services.
1. Click or tap here to enter text.
2. Click or tap here to enter text.
3. Click or tap here to enter text.
4. Click or tap here to enter text.
5. Click or tap here to enter text.
6. Click or tap here to enter text.
7. Click or tap here to enter text.
8. Click or tap here to enter text.
9. Click or tap here to enter text.
10. Click or tap here to enter text.
14. List current activities on which your firm is the designated Engineer of Record
Project Name, Type
& Location
Total Number of Projects:
Name & Address of Owner
Nature of Firm’s
Responsibility
Estimated Construction
Cost
Percent Complete
Total Estimated Construction Costs: $
8
15. List current activities on which your firm is serving as a sub-consultant to others.
Project Name, Type
& Location
Nature of Firm’s
Responsibility
Name & Address of
Owner
Estimated Completion
Date
Estimated Construction Cost
Entire Project
Your Firm’s
Responsibility
16. List completed work within the last 5 years on which your firm was the designated Engineer of Record.
Project Name, Type
Name & Address of Owner
Estimated Construction Cost
& Location
Year
Constructed
(Yes or No)
17. List completed work within last 5 years on which your firm has been a sub-consultant to other firms. (Indicate phase of work which your firm
was responsible.)
Project Name, Type
Name & Address
Estimated Construction
Year
Constructed
Firm Associated With
& Location
of Owner
Cost of Your Firm’s Portion
(Yes or No)
9
18. Use this space to provide any additional information or description of resources supporting your firm’s qualifications to perform work for the
West Virginia Land Stewardship Corporation on mine land reclamation and mine drainage water treatment.
Click or tap here to enter text.
19. The foregoing is a statement of facts, attested to by:
Signature: ________________________________________________
Date: _______________________________
Title:
Printed Name: __
__________________________________________
10
BOND FORFEITURE and RELATED PROJECT EXPERIENCE MATRIX
Primary staff participation/capacity
*** M-Management P-Professional
NPDES/ Stormwater
preparation
Geotechnical/stability
Stream restoration
Equipment /structure removal
Water treatment
Construction inspection /
management
Water quality evaluation
/mitigation replacement
Project specifications
Hazardous waste disposal
Subsidence investigation/
mitigation
Mine / refuse fire abatement
Remining Evaluation
Additional
info
provided in
Section (s)
**
Hydrologic/Hydraulic design/
Eval.
C-Corp
P-Personal
*
Portal/shaft closure
Exp. Basis
Forfeited Deep Mine
Reclamation
PROJECT
Forfeited Surface Mine
Reclamation
PROJECT EXPERIENCE REQUIREMENTS
*List whether project experience is corporate or personnel based or both
** Use this area to provide specific sections or pages if needed for reference
*** List primary design personnel and their functional capacity for the projects listed.
11