8000-PM-OOGM0001 Rev. 1/2016
    COMMONWEALTH OF PENNSYLVANIA
    Instructions
    DEPARTMENT OF ENVIRONMENTAL PROTECTION
    OFFICE OF OIL AND GAS MANAGEMENT
    - 1 -
    INSTRUCTIONS FOR COMPLETING AN APPLICATION FOR A PERMIT
    TO DRILL OR ALTER AN OIL OR GAS WELL
    Form 8000-PM-OOGM0001
    GENERAL INFORMATION
    These permit application forms are used to apply to Pennsylvania‟s Department of Environmental Protection
    (Department), for approval to drill a new oil or gas well, or to redrill, alter or deepen an existing well, renew a permit
    about to expire, and to repermit an expired well permit. Section 3211(a) of 58 Pa.C.S. §§ 3201-3274 (2012 Oil and
    Gas Act) requires operators to obtain a well permit prior to drilling or altering a well. 58 Pa.C.S. § 3211(a).
    Additionally, pursuant to Section 3259 of the 2012 Oil and Gas Act, it is unlawful to drill, alter, operate or utilize an oil
    or gas well without a permit or registration from the Department as required by the 2012 Oil and Gas Act or in
    violation of rules and regulations adopted under the 2012 Oil and Gas Act, orders of the Department or a term or
    condition of a permit issued by the Department. 58 Pa.C.S § 3259.
    The forms required for a complete application are dependent upon the type of well permit being applied for. The
    forms are divided first by:
    a) Conventional wells – Wells that are not unconventional wells, irrespective of technology or design. The term
    includes wells drilled to produce oil, wells drilled to produce natural gas from formations other than shale
    formations, wells drilled to produce natural gas from shale formations located above the base of the Elk
    Group or its stratigraphic equivalent, wells drilled to produce natural gas from shale formations located below
    the base of the Elk Group where natural gas can be produced at economic flow rates or in economic
    volumes without the use of vertical or nonvertical well bores stimulated by hydraulic fracture treatments or
    multilateral well bores or other techniques to expose more of the formation to the well bore, and wells drilled
    for collateral purposes, such as monitoring, geologic logging, secondary and tertiary recovery or disposal
    injection.
    b) Unconventional wells which target unconventional formations defined as a geological shale formation
    existing below the base of the Elk Sandstone or its geologic equivalent stratigraphic interval where natural
    gas generally cannot be produced at economic flow rates or in economic volumes except by vertical or
    horizontal well bores stimulated by hydraulic fracture treatments or by using multilateral well bores or other
    techniques to expose more of the formation to the well bore.
    c) Wells in coal areas- If the proposed well is on a coal area or a coal bed methane well, complete and attach
    the coal module. If the proposed well is in a non- coal area attach a. justification as to why the area is
    considered a non-coal area. The coal module would not be required for a proposed well in a non-coal area.
    The a, b, or c suffix applicable to the above groupings will be shown in the upper left of the form after the
    001 numbering of the form. Ex: 8000-PM-OOGM0001a.
    Several additional forms may be required with your application, depending on the type of well, bond agreement, or
    variances requested. The forms typically provide entry for one piece of information. If you have situations that require
    additional information for multiple entries, attach additional sheets with the Operator, farm name, well identified at the
    top of each additional sheet and identify the addition informational field/data being provided. A permit fee is also
    required. Please read through this application form and instructions to determine which additional forms and
    supporting documents you need. The forms for permits and approvals are available to the public from DEP‟s
    website, at
    www.dep.pa.gov
    . Click on the phrase Permits, Licensing and Certification at the left of the screen, select
    Program-Specific Permit/Authorization Packages then click on the Oil and Gas Management folder.
    If completing forms manually, please type or print legibly. Unreadable information will delay processing, and may
    result in your application being returned to you.
    Information required on these forms is mostly self-explanatory. Instructions are written only for those items that need
    some explanation. If an item is not relevant to your application, enter “NA” in that space rather than leave the space
    blank.
    Before generating waste, oil and gas well operators are required by 25 Pa.Code § 78.55 (relating to control and
    disposal plans) to prepare and implement a control and disposal plan under 25 Pa.Code § 91.34 (relating to activities
    utilizing pollutants). The plan must address the control and disposal of residual waste, drill cuttings and fluids,
    including tophole water, brines, drilling fluids, additives, drilling muds, stimulation fluids, well servicing fluids, oil,
    production fluids and drill cuttings from the drilling, alteration, production, plugging or other activity associated with oil
    and gas wells. Operators can meet these regulatory requirements and the requirements under 25 Pa.Code § 78.55

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    and 25 Pa. Code § 91.34 by developing and implementing a site specific Preparedness, Prevention and Contingency
    (PPC) Plan.
    Copies of the plan(s) must: (1) Be provided to the Department upon request; (2) Be available at the well site during
    earth disturbance activities, drilling, completion and alteration activities for use by those involved in those activities
    and for review by DEP; and (3) Include a list of emergency contact phone numbers for the area in which the well site
    is located. The emergency contact phone numbers must be prominently displayed at the well site during drilling,
    completion or alteration activities.
    See
    25 Pa. Code § 102.5(l).
    Pursuant to Section 3221 of the 2012 Oil and Gas Act, a well operator may request permission to use a method or
    material other than those required by the 2012 Oil and Gas Act and applicable regulations for casing. Plugging or
    equipping a well, please submit alternate methods or materials requests along with your permit application.
    A checklist is included for this application form for your use. Please use it to check that your application is complete
    before you submit the application to DEP. Incomplete, illegible, or inadequate applications may be returned. You do
    not need to submit the checklist with your application.
    If you do not have an oil and gas well bond in effect now, you should complete the bond application process before
    submitting your application for an oil or gas well permit. Your well permit will not be issued until your bond is
    approved.
    If your bond is already in effect, you must identify the bond agreement number on your permit application form that
    serves as the Exhibit A (Form 8000-FM-OOGMO0042), which identifies this well is to be added to your bond. When
    your bond is accepted by the Department, you should record the bond agreement number provided by DEP. If you
    have multiple bonds, you should make sure the amount of coverage available for that particular bond is sufficient to
    allow the well permit being applied for can be covered by the specific bond.
    If you have any questions about this application, or need more information or additional forms, contact the
    appropriate DEP regional oil and gas office. Refer to the regional permitting office map at the end of these
    instructions. Note that for purposes of submitting applications for well permits, your application is to be submitted to
    the applicable well permitting office that covers the county in which the well will be located. There are two well
    permitting offices as shown on the “permitting office map.”
    PA DEP
    Oil and Gas Management Program
    Northwest Regional Office
    Phone 814-332-6860
    230 Chestnut Street
    Fax 814-332-6121
    Meadville, PA 16335-3481
    PA DEP
    Oil and Gas Management Program
    Southwest Regional Office
    Phone 412-442-4024
    400 Waterfront Drive
    Fax 412-442-4328
    Pittsburgh, PA 15222-4745
    If you have problems using the forms on your personal computer or printing them, please contact:
    PA DEP
    Bureau of Oil and Gas Management
    PO Box 8765
    Phone 717-772-2199
    Harrisburg, PA 17105-8765
    Fax 717-772-2291
    Well Operator - Applicant Name
    Enter the name of the business or individual that will be the operator of this well. The Well Operator name on this
    permit application form must exactly match the Operator Name on the applicant„s bond.
    DEP will issue a permit only to a legal entity, e.g., an individual doing business in his or her own name or in a
    registered fictitious name, or to a duly registered corporation, partnership, or limited liability company. A fictitious
    named business or organization must already be registered with the Pennsylvania Department of State before DEP
    will process a permit application.
    Proof of incorporation or registration of a fictitious name must be provided with the bond application via the General
    Information form (
    8000-FM-OOGM0099) and the Ownership and Control form (8000-FM-OOGM0118.)
    DEP Client ID No.
    is the applicant„s unique eFACTS identification number with the Department of Environmental
    Protection. It will be common to all the applicant„s business with the department. Your DEP Client ID number has

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    already been assigned, or will be assigned when we process your bond application. If you do not know your DEP
    Client ID number, please call one of the regional offices, or the Office of Oil and Gas Management in Harrisburg.
    Mailing Address
    Enter the well operator‟s current mailing address. Operators are required to notify the department in writing of an
    address change within 30 days of a change.
    If you have listed a new address, but have not yet notified a regional DEP Oil and Gas office, please check the box
    indicating that this is a new address. Include the change of address notice on an attached sheet on company
    letterhead.
    WELL INFORMATION
    Enter the farm name, well number, and if applicable, the “serial number” you assigned to the well for your tracking
    purposes and project number assigned by DEP as applicable. The Farm Name, Well Number and Serial Number
    are the applicant„s designations to identify the well. Project number is a designation assigned to a group of wells
    associated by production field or farm. If applicable, this number would have already been, or will be assigned by
    DEP.
    Previous Permit or Registration
    If the well was previously permitted or registered and you are applying to drill deeper by extending a lateral or adding
    a new lateral, redrilling the wellbore to the same depth, altering the well which includes changing casing in a coal
    well, repermiting an expired permit, or renewing an active permit,
    enter the API
    number assigned to the well from the
    last permit issued for that well and specific lateral the application pertains to by including the 11
    th
    to 14
    th
    digits of the
    API number.
    For an existing well that has no DEP permit or registration identification, please provide all available information
    known about the well. Provide records that you have, such as: date drilled, ownership documents, well record,
    driller‟s log, geophysical log, production data, year last produced or other relevant information that is available for the
    well.
    Location
    Provide the true Latitude and Longitude of the surface location of the wellbore. This should be the same as shown
    on the plat and be in NAD 83 datum.
    County and Municipality
    Enter the name of the county and municipality of the surface location of the proposed well. If you are using DEP‟s
    on-screen “smart forms,” select the county name from the drop-down list. Strike the F1 key on your keyboard for the
    county list. Alternately, type in the municipality name and the appropriate designation of type. Ex.: City, Borough
    (Boro) or Township (Twp).
    USGS Quad and section
    Enter the name of the quadrangle map and section of the quad the well is to be located on. This should be the same
    as shown on the plat.
    Emergency contact information
    Enter the name of who will be the responsible contact individual for the well during site and well development.
    Provide the 24/7 phone contact number for that person.
    Provide the 911 address of the well site if it has been assigned.
    Related Facilities
    Provide the name/identification and/or permit number for the following facilities that are or will be used in the
    development of the well:
    ?
    ESGP Permit No.: If an ESGP has been issued for the well site, provide the permit number of the ESGP.
    ?
    Freshwater Impoundment: Provide the name you assigned to the freshwater impoundment that will be
    utilized to store and provide fluid for well drilling/completion activities for the well.
    If multiple, attach
    additional sheets with the Operator, farm name, well identified at the top of each additional sheet and identify
    the additional information field/data being provided.
    ?
    Centralized Wastewater Impoundment: Provide the name or permit number of the centralized impoundment
    that will be utilized to store and provide fluid for well drilling/completion activities for the well.

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    ?
    Borrow Area/Gravel Pit: Provide the name or permit number of the non-commercial borrow/gravel pit area
    from which material is to be removed under terms of a lease agreement that will be used to construct this
    well site.
    ?
    Well pad name: Provide the name you assigned to the well pad if multiple wells are to be drilled from the
    same well site pad.
    Well Development Details
    Provide details for the following:
    Surface Elevation – Above sea level in feet of the proposed ground (well site/pad) level at the wellbore;
    Deepest formation of all laterals to be penetrated. If drilling a pilot or rat hole to allow logging of the bottom of the
    proposed producing formation, list deepest formation to be penetrated to allow for the logging tool.
    Anticipated True Vertical Depth (TVD) of the (preceding) deepest formation from the surface elevation;
    Target Formation proposed for production. List all formations planned to be produced;
    Anticipated Target Top/Bottom TVD Provide anticipated True Vertical Depth of the top and bottom of the target
    formations from the surface elevation.
    Wellbore laterals –
    Enter the number of laterals to be drilled and the total feet of wellbore to be drilled of all laterals
    combined as proposed under this application.
    Threatened and Endangered Species
    Proof of consultation with Pennsylvania Natural Heritage Program‟s (PNHP) Pennsylvania Natural Diversity Inventory
    (PNDI) is required. To ensure compliance with federal and state law, submit a Pennsylvania Natural Diversity
    Inventory Project Environmental Review Receipt (PNDI receipt).
    If the PNDI receipt identifies a conflict with
    threatened or endangered species, it will provide an explanation of the potential impact(s) and instructions on how to
    resolve the potential impact.
    See
    Technical Guidance Document No. 400-0200-001, Policy for Pennsylvania Natural
    Diversity Inventory (PNDI) Coordination During Permit Review and Evaluation.
    Note for renewals: a new PNDI run must be done if the prior run submitted with the previously approved application
    is not within a year of the renewal application. Also, if re-run of PNDI has a different outcome, the conditions of the
    prior application have changed and the applicant must submit a new application (instead of renewal) with an updated
    clearance letter from controlling agency(ies). This may impact outcome of Special Conditions so PNDI change would
    not be a renewal. Note that application has changed but can still apply to originally assigned API No. for the well.
    PERMIT TYPE
    Please check the appropriate descriptions of the activity to be permitted and the type of well.
    Application is for:
    Drill New Well:
    A location where no well has ever been drilled.
    Renew Active Permit:
    Submitting application to renew permit at least 15 days prior to expiration of the permit.
    Provide prior API No.
    Repermit expired permit:
    Application for a permit to drill a well at a location that was previously issued a permit
    that has since expired. Provide prior API No.
    Deepen, Re-drill, or Alter an Existing Well:
    Provide prior API No. and check the appropriate box.
    Deepen:
    To drill an existing well below the original total depth.
    Re-drill:
    To drill out a plugged well for the purpose of putting a plugged and abandoned well into production.
    Alter:
    Any operation that changes the use or purpose of a well, for example to change an oil production well
    to an injection well. (Also check the appropriate box under TYPE OF WELL it will become), or drills out
    the well bore, or, depending on the work, it may include removing, repairing or changing the casing.
    (Remove, repair, or change casing means to alter the casing by changing the depth or diameter of the
    well, or to remove, repair or change casings in coal areas. Replacement of casing of the same
    diameter to the same depth is not by itself an alteration.
    In coal areas, changing or repairing the production casing where it is also the coal protective casing is
    an alteration requiring a permit. Work on the production string that affects the coal protective casing is
    an alteration, which requires a permit.
    If the application is for something other than above, check “Other” and write in the intended purpose.

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    TYPE OF WELL
    Mark the box indicating the type of well that will result from the intended activity. Check OTHER for any type not
    listed, and fill in a very brief description.
    CONFIGURATION
    Check the major manner of how the wellbore(s) applied for under this application will be constructed. If there is a
    vertical pilot component of the well but the pilot is primarily to build the horizontal portion of the well, check horizontal.
    If the application is only for a vertical wellbore, check vertical. If the wellbore is intended to be deviated from vertical
    by more than 3 degrees, check deviated. If there will be multiple wellbores/laterals drilled horizontally check both
    horizontal and multiple laterals checkboxes.
    APPLICATION FEE
    Check the box for the applicable permit application fee. Associated well types are shown in parentheses. The whole
    fee must accompany the permit application. The amount depends on the type of well being permitted and, for
    conventional wells, the length of wellbore to be drilled under this permit. The application fee consists of a permit fee
    and surcharges where applicable which are paid into the orphaned and abandoned well plugging funds. Application
    fees are not refundable.
    The specific amount is calculated as follows:
    Gas Well
    [includes gas storage wells, combination gas & oil wells (in non-coal areas only), and coalbed methane
    wells]: Application Permit fee + $250 (Surcharges). If coal bed methane is checked and you intend to drill a coal
    bed methane well or construct an access road associated with a coal bed methane well you are required to
    provide written notification to the surface owner in the manner prescribed in section 201(B) of the act of
    December 19, 1984 (P.L. 1140 No. 223), known as the “Oil and Gas Act”. The notification shall include the
    following statement (on DEP Form 5500-FM-OG0053).
    Oil Well
    (including injection - recovery wells):
    Application Permit fee + $150 (Surcharges)
    Home Use Gas/Oil Well:
    $200 (permit fee) + $250/$150 (surcharges)
    Injection - Disposal Well:
    Application Permit fee (Permit fee) + $50 (Surcharge)
    Redrill / Drill Deeper:
    Application Permit fee + $0 (Surcharge)
    Alteration:
    $100 (Permit fee) + $0 (Surcharge) = $100 (Application Fee)
    Change in Use
    (change the use of an existing well):
    $100 (Permit fee) + $0 (Surcharge) = $100 (Application Fee)
    UNCONVENTIONAL WELLS
    The permit fee for unconventional wells must include the new permit application fee in addition to the surcharge fees
    for abandoned and orphan wells. The new permit fee is as follows:
    $4,200 for a vertical unconventional well.
    $5,000 for a nonvertical unconventional well.
    If the well is unconventional, check the applicable well status box, either vertical or nonvertical. Enter the Total
    Application Fee amount from the last line below on the Application Form.
    If the application is for a unconventional well and the applicant proposes to use water from water sources within the
    Commonwealth for well fracing activities, the applicant must do so in accordance with a Water Management Plan
    approved by the Department. Please refer to document number 5500-PM-OG0087 for an example format of a water
    management plan.
    Unconventional Permit Fee
    $
    Orphan well surcharge
    $200.00/$100.00
    Abandoned well surcharge
    $50.00
    Total application fee
    $

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    CONVENTIONAL WELLS
    The permit fee for a conventional well must include the following permit application fee in addition to the surcharge
    fees for abandoned and orphan wells. The conventional well permit fee is as follows:
    Total Wellbore Application Fee Length in Feet 0 To 2,000
    $250
    2,001 To 2,500
    $300
    2,501 To 3,000
    $350
    3,001 To 3,500
    $400
    3,501 To 4,000
    $450
    4,001 To 4,500
    $500
    4,501 To 5,000
    $550
    5,001 To 5,500
    $650
    5,501 To 6,000
    $750
    6,001 To 6,500
    $850
    6,501 To 7,000
    $950
    7,001 To 7,500
    $1,050
    7,501 To 8,000
    $1,150
    8,001 To 8,500
    $1,250
    8,501 To 9,000
    $1,350
    9,001 To 9,500
    $1,450
    9,501 To 10,000
    $1,550
    10,001 To 10,500
    $1,650
    10,501 To 11,000
    $1,750
    11,001 To 11,500
    $1,850
    11,501 To 12,000
    $1,950
    An applicant for a conventional well exceeding 12,000 feet in total well bore length shall pay a permit application fee
    of $1,950 + $100 for every 500 feet the well bore extends over 12,000 feet. Fees shall be rounded to the 500-foot
    interval.
    The orphan well surcharge is $200 for a gas well or $100 for an oil well. The abandon well surcharge is $50. These
    surcharges are in addition to the permit application fees above. Total permit application costs for conventional wells
    must equal three (3) components: permit application fee + $50 abandoned well surcharge + $200 or $100 orphan
    well surcharge. The surcharges as established by the Oil and Gas Act fund the Orphan and Abandoned Well
    Plugging Program.
    Conventional Permit Fee
    $
    Orphan well surcharge
    $200.00/$100.00
    Abandoned well surcharge
    $50.00
    Total application fee
    $
    You can also use the on-line Well Permit Fee Calculator that can be found for your use at the bottom of the DEP Oil
    and Gas Industry Resources web page at:
    http://www.portal.state.pa.us/portal/server.pt/community/industry_resources/20301
    Make your check or money order payable to the “Commonwealth of Pennsylvania.” For your convenience, you may
    pay with one check for all applications submitted at the same time. Attach the payment to the front of the application
    form. Personal and business checks are acceptable.
    Oil and Gas Conservation Law
    A “non-conservation well” is a well not subject to the Oil and Gas Conservation Law, 58 PS §401
    et seq.
    This law
    applies to any well (drilled after July 25, 1961) drilled deeper than 3800 feet which also penetrates the Onondaga
    horizon. All development wells in a pool discovered by a conservation well are also subject to the law, regardless of
    completion depth or horizons penetrated. No gas storage well is subject to this law. Deepening an old well as
    described above would subject it to this law. If in doubt, please call DEP‟s district oil and gas office to find out.
    The Oil and Gas Conservation Law also established spacing criteria for wells subject to the law. Some areas of the
    state are covered by specific spacing orders that were issued by the department; elsewhere spacing regulations
    apply. Maps of areas covered by spacing orders are filed in the office of the Recorder of Deeds in the respective
    county, as well as the DEP office for the region. For details,
    see
    58 PS §401 et seq.; 25 Pa. Code §79. The

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    Instructions
    DEPARTMENT OF ENVIRONMENTAL PROTECTION
    OFFICE OF OIL AND GAS MANAGEMENT
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    Pennsylvania Code of Regulations is available from the website www.pacode.com. Environmental Protection is
    Title 25. For Chapter 79, click on this hyperlink: 25 Pa. Code Chapter 79.
    Conservation wells, to be drilled in areas that are not covered by spacing orders, may be located no closer than
    330 feet from the outside boundary of the lease or unit.
    Coal Mining & Coal Resources
    Certain regulations on casing, spacing, and resource coordination apply to a well that will penetrate a coal seam
    workable by underground mining methods. As defined in 25 Pa. Code § 78.1, a coal area is “an area that is
    underlain by a workable coal seam.”
    For a proposed location in a county with known mineable coal seams, when declaring that a proposed well location is
    not in a coal area, the applicant must provide written justification, supporting documentation, and publication
    references, if available, to support the “non-coal” declaration. Acceptable information could be, for example, coal
    operator‟s bore hole logs, exploratory core hole logs, etc. For a location in a county where there are no known
    workable coal seams, you need not provide support for a non-coal area declaration.
    See DEP policy guidance for detailed criteria defining a “workable coal seam,” as well as a list of acceptable
    published references. For advice or further explanation, contact the oil and gas permits chief at one of the DEP
    regional offices.
    The distance restriction for a gas well which is not subject to the Oil and Gas Conservation Law, but which
    penetrates a workable coal seam is at least 1,000 feet from all other existing wells unless the wells are grouped on a
    well pad in a well cluster of no more than 5,000 ft.
    2
    with the center of the well bore of the nearest well (not part of this
    cluster) is not less than 2,000 ft.to the center of the wellbore of the nearest well in the cluster. Any request for
    exception from these distance requirements must be specific, in writing, and accompany this application. A request
    for exception from 1000-foot well-spacing must be signed by all coal owners, as listed on the record of notification
    page (page 2) of the application form Coal Module 8000-FM-OOGM0001(c).
    See
    58 P.S. § 507.
    If the proposed well location is within the permitted boundaries of an underground coal mine, or within 1,000 feet of a
    boundary of the mining permit area, the applicant is required to notify those coal owners and operator. Notification
    must be by certified mail, with a copy of this permit application, including the well location plat on form
    8000-PM-OOGM0002.
    See
    Section 3211(b)(2) of the 2012 Oil and Gas Act. The coal owners and operators may
    give written approval of the proposed well location by signing page 2 of the permit application Coal Module
    8000-FM-OOGM0001(c).
    If you are not sure whether your proposed well‟s location falls within the coordination area of an underground coal
    mine as described above, please contact DEP‟s mine permits office at:
    California District Office
    25 Technology Drive
    California Technology Park
    Coal Center, PA 15423
    Phone: 724-769-1100
    Fax: 724-769-1102
    Gas Storage Fields
    If the proposed well location is within a gas storage area, or within the reservoir protective area, the applicant must
    notify the gas storage operator of this well permit application, and submit proof of notification with this application.
    Notification must be by certified mail with a copy of this permit application, including the well location plat on form
    8000-PM-OOGM0002. The protective area is nominally 2,000 feet from the boundary of the storage area unless
    otherwise designated by the Department. However, if the proposed well is an unconventional well, notification is
    required if your proposed well is within 3,000 feet from the boundary of the storage area.
    Landfills
    If the proposed well location is within the perimeter of an abandoned, active, or permitted landfill, draw and label the
    approximate perimeter of the landfill on the well location plat. Identify the owner/operator of the landfill, if known.
    Location of Disturbed Area
    If the limit of the disturbed area of the well site is within 100 feet from a wetland larger than one acre, or any blue
    lined spring, stream or body of water identified on the most current 7 ½-minute USGS topographic map, submit a site
    specific Erosion and Sedimentation Control Plan (unless an Erosion and Sedimentation Control General Permit is
    otherwise required for the well site), and portions of the well site Pollution Prevention Control Plan that demonstrates

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    there will be adequate protection of the Water of the Commonwealth. In the case of an unconventional well, this
    demonstration should include those relevant portions of the well site Emergency Response Plan and Site
    Containment Plan.
    If the well site, access road, or pipeline encroaches on a watercourse, body of water, or wetland, the applicant may
    also be required to obtain a permit for water obstructions and encroachments.
    A conventional well may not be drilled within 200 feet of an existing building or water well, without the prior written
    consent of the owner. The distances for a unconventional well require the vertical wellbore to be 500 feet from a
    building or water well and may not be drilled less than 1,000 feet from any existing water well, surface water intake,
    reservoir or other water supply extraction point utilized by a water purveyor. Written consent may be in the form of
    the owners‟ signatures in the appropriate spaces on page 3 of the permit application form, or in a letter or form
    created by the applicant or consenter. If the owners of the water well, building or water purveyor do not consent in
    writing, the applicant may submit a “Request for Variance from Distance Restriction” (form 8000-FM-OOGM0058) to
    the department detailing the additional terms and conditions to be in place to ensure safety and protection persons
    and property.
    Public Resources
    The Department has constitutional and statutory obligations to protect public resources. For example, Section
    3215(c) of the 2012 Oil and Gas Act requires the Department to consider the impact of the proposed well on various
    public resources when making a determination on a well permit 58 Pa. C.S. §3215 (c). 58 Pa. C.S. § 3215(c),
    see
    also
    58 Pa. C. S. §§ 3202 and 3211(e.1)(1). Additionally, the Department shares responsibility for the protection of
    natural resources with other Commonwealth agencies and municipalities. Public resources include publicly owned
    parks, forests, game lands, designated wildlife areas, national or state scenic rivers, national natural landmarks,
    habitats of rare and endangered flora or fauna (threatened and endangered species), other critical communities
    (species of special concern), and historical and archaeological sites listed on the federal or state list of historic
    places, and water wells, surface water intakes, reservoirs or other water supply extraction points used by a water
    purveyor within 1000 feet of a proposed unconventional well.
    To ensure compliance with applicable constitutional and statutory obligations, if you answer “Yes” to question 6, you
    must also complete and submit the form “Coordination of a Well Location with Public Resources” (form 5500-PM-
    OG0076). See the instructions for that form for more details.
    For threatened and endangered species, please see “Threatened and Endangered Species” section above.
    For species of special concern, well permit applicant must identify the habitats of special concern species where the
    proposed well site or access road will be located and describe any means proposed to be taken to avoid or mitigate
    impacts to special concern species. The applicant must provide documentation that it has consulted with the
    Pennsylvania Natural Heritage Program‟s (PNHP) Pennsylvania Natural Diversity Inventory (PNDI) by submitting a
    Pennsylvania Natural Diversity Inventory Project Environmental Review Receipt (PNDI receipt). Applicants may use
    the same PNDI receipt run for threatened and endangered species.
    If the PNDI receipt identifies a conflict with a special concern species, please refer to Technical Guidance Document
    No. 400-0200-001, Policy for Pennsylvania Natural Diversity Inventory (PNDI) Coordination During Permit Review
    and Evaluation, Appendix C.
    Special Protection Watersheds
    If the proposed well location is in a High Quality or Exceptional Value watershed, check the “Yes” box and enter the
    name of the special protection stream. Maps and other information on special protection waters are available on
    DEP‟s website at:
    http://www.dep.state.pa.us/dep/deputate/watermgt/wqp/wqstandards/antideg/antideg.htm.
    For listings of specific streams and segments, consult 25 Pa. Code §93.9, Designated Water Uses and Water
    Quality Criteria, and Existing Use list. These documents are available on the World Wide Web at:
    http://www.pacode.com/secure/data/025/chapter93/s93.9.html
    and
    http://www.dep.state.pa.us/dep/deputate/watermgt/wqp/wqstandards/existuse/existuse.htm
    A person proposing to drill an unconventional well or a well that utilizes enhanced drilling or completion technologies
    to produce gas that involves 1 to 5 acres of earth disturbance over the life of the project and is located in a watershed
    that has a designated or existing use of High Quality or Exceptional Value pursuant to 25 Pa. Code Chapter 93
    (relating to water quality standards) must demonstrate compliance with antidegradation regulations under 25 Pa.
    Code Chapters 93 and 102 prior to the commencement of any earth disturbance activities.

    8000-PM-OOGM0001
    Rev. 1/2016
    Instructions
    - 9 -
    Centralized Impoundments
    To determine what permit or approval is required for each pit or dam associated with Marcellus Shale gas well
    development, please refer to the Department worksheet 5500-PM-OG0086 entitled, Worksheet for Permitting of
    Marcellus Shale Pits and Dams located on the Marcellus Shale Page on the DEP website under “Application for a
    Dam Permit for a Centralized Dam Impoundment for Marcellus Shale Gas Well”.
    Erosion and Sediment Control Permits
    Pursuant to 25 Pa. Code § 102.5(c), “[a] person proposing oil and gas activities that involve 5 acres (2 hectares) or
    more of earth disturbance over the life of the project shall obtain an E&S Permit under [25 Pa. Code Chapter 102]
    prior to commencing the earth disturbance activity.”
    Non-liquid Waste disposed of on the well site.
    If you will be disposing drill cuttings pursuant to 25 Pa. Code § 78.61 or residual wastes pursuant to 25 Pa. Code
    §§ 78.62-78.63 on the well site indicate by checking the yes box. Otherwise, check the No box.
    Floodplain precautions
    If the well or well site will be located within a defined 100 year floodplain or where the floodplain is undefined, within
    100 feet of the top of the bank of a perennial stream or within 50 feet of the top of the bank of an intermittent stream
    indicate by checking the applicable box, Yes or No. If yes, submit a site specific Erosion and Sedimentation Control
    Plan (unless an Erosion and Sedimentation Control General Permit is otherwise required for the well site), and
    portions of the well site Pollution Prevention Control Plan that demonstrates there will be adequate protection of the
    Waters of the Commonwealth. In the case of an unconventional well, this demonstration should include those
    relevant portions of the well site Emergency Response Plan and Site Containment Plan.
    Signature of Applicant
    If the well operator is an individual, either doing business in his own name or under a fictitious name (registered or
    not), he must sign his own name. Individuals in joint ownership must authorize one person to sign on behalf of all;
    attach the authorizing resolution or power-of-attorney.
    An unincorporated business entity using a fictitious (business) name must have the name registered with the
    Corporation Bureau of the Pennsylvania Department of State. Only an owner or an individual duly authorized by the
    owners of such a business may sign this permit application.
    If the well operator is a partnership, the application must be signed by all partners, or an authorized general partner.
    Attach the authorizing resolution. Use additional attachments for signatures if needed.
    If the well operator is a corporation, the application must be signed by an authorized corporate officer. Attach the
    authorizing resolution.
    A well operator may empower another person, by specific power-of-attorney, to sign permit applications on behalf of
    the operator. To change this designation, include a new power-of-attorney with the permit application.
    Names and titles must be printed or typed next to each signature. Words crossed out, or other corrections, must be
    initialed and dated by all parties signing this form.
    Be advised that a signatory to this form attests to the truthfulness of the information in the application and all
    supporting documents, and would be subject to penalty for falsification of any information in this application
    (18 Pa CS §4904).
    Record of Notification / Written Consent
    Instructions and explanation for page 3 of the application form.
    Fill in “Applicant Name” and “Farm Name - Well No.” in the upper right corner of the form. Leave “Application
    Tracking No.” blank.
    Use this form to record and report the names and addresses of all parties whose interests may be affected by the
    proposed well or activity that is: surface ownership, water supply, and water purveyor sources and gas storage
    operations. If you need more spaces for listings, use additional forms.
    An applicant for a well permit is required to notify certain parties of this application. Send a copy of it by certified mail
    to:
    ?
    The surface landowner, addressed to the names and addresses of landowners as recorded by the county
    real estate tax office (See the note below for Commonwealth lands owned by the Department of
    Conservation and Natural Resources).

    8000-PM-OOGM0001 Rev. 1/2016
    COMMONWEALTH OF PENNSYLVANIA
    Instructions
    DEPARTMENT OF ENVIRONMENTAL PROTECTION
    OFFICE OF OIL AND GAS MANAGEMENT
    - 10 -
    ?
    All surface landowners or water purveyors whose water supplies are within 1,000 feet of the proposed
    well location of a conventional well and if the well proposed is an unconventional well all surface
    landowners or water purveyors whose water supplies are within 3,000 feet of the vertical wellbore.
    ?
    The owners and lessees of all underlying workable coal seams.
    ?
    Every coal operator or (underground) mining permit holder, as required. This includes any coal operator
    with a permitted underground mine boundary within 1,000 feet of the proposed well location.
    ?
    Gas storage operator, if the proposed well location is within a gas storage or reservoir protective area
    (nominally, within 2,000 feet of the perimeter of the storage area).
    If the proposed well is an
    unconventional well, the distance is 3,000 feet from the vertical well bore to the perimeter of the storage
    area.
    Notification if on DCNR lands:
    If the landowner is the Commonwealth‟s Department of Conservation and Natural Resources (DCNR), send the
    notice to:
    PA DCNR
    Bureau of Forestry, Minerals Section
    PO Box 8552
    Harrisburg, PA 17105-8552
    Please do not send the notification to the local Forestry or Parks office of DCNR. This applies to all state lands
    under the control of the Department of Conservation and Natural Resources, such as state parks, state forests,
    undeveloped conservancies, and wilderness areas. It does not apply for state lands controlled by other agencies
    such as the Game Commission, Fish & Boat Commission, Department of Agriculture, and any other state agency
    except DCNR.

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