1. PERMIT APPLICATION TO DRILL AND OPERATE A WELL
    2. COAL MODULE
    3. COAL MODULE
    4. RECORD OF NOTIFICATION / WRITTEN CONSENT

8000-PM-OOGM0001c Rev. 2/2017
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OFFICE OF OIL AND GAS MANAGEMENT
- 1 -
PERMIT APPLICATION TO DRILL AND OPERATE A WELL
COAL MODULE
Coal module attachment to address coal related issues with drilling, altering, or operating wells.
Yes
No
1. Will the well penetrate a
workable coal seam
?
If “No,” attach justification and supporting documentation
a. Have the coal rights been severed from the surface estate
2.
If the well will penetrate a
workable coal seam
and the well is a “non-conservation” gas well,
does the location comply with the distance requirements of section 7 of the Coal and Gas
Resource Coordination Act? (At least 1,000 feet from all existing wells). 58 P.S. §§ 501 - 518.
a.
If “No,” is the required exception request attached? (Check N/A if re-working an existing well:
N/A)
b.
Will the well be part of a Well Cluster that is an area within a well pad intended to host multiple
horizontal wells and which comprises an area no greater than 5,000 square feet?
3. Will this well be drilled in solid coal or into an open underground void?
solid coal
open void
Yes
No
4. Will the well be drilled through an
operating coal mine
, or within 1,000 feet of the boundary?
a.
If “Yes,” provide the names of: Mine
and Operator
b.
If yes, does it meet the Gas Well Pillar Study? 58 P.S. § 512.1.
c.
If yes, provide a copy of the most recent underground mine workings map that shows well
location, a map scale, the lease/unit boundary, and a north arrow.
5. If the well will be a Coal Bed Methane (CMB) well is the alternate method request of
drilling/completing the well attached
Proposed Alternate Method or Material for Casing, Plugging,
Venting or Equipping a Well
form 8000-PM-OOGM0024?
6. If the well is a CBM well, has the surface landowner been notified and provided a copy of
Landowner Notification of Right to Participate in Alternate Dispute Resolution to Coal Bed
Methane Wells
, form 8000-FM-OOGM0052?

8000-PM-OOGM0001c
Rev. 2/2017
- 2 -
COAL MODULE
RECORD OF NOTIFICATION / WRITTEN CONSENT
List the following: all coal owners and lessees of all underlying
coal seams; operators of operating coal mines at the proposed
location; and coal operators with Operating Coal Mine. Mark the
boxes
“X
” that show the parties’ interests. Use additional forms
if you need more space. You are required to notify each of these
parties.
Coal Owner
Coal Lessee
Operator of Operating
Coal Miner
Within
1,000
ft.
Notification
Note the Means and Attach Proof
Coal Mine
Operator
Certified Mail
Dates
Address
Affidavit
Written
Sent
Consent
Return
Receipt
Name
Address
Name
Address
Name
Address
Name
Address
Name
Address
Optional: Signature below indicates the party’s approval of the well location and waives the 15-day objection period.
Check
applicable box.
Coal
Operator,
Owner, or
Lessee
Date
Coal
Operator,
Owner, or
Lessee
Date
Coal
Operator,
Owner, or
Lessee
Date
Coal Operator within 1,000 feet of proposed location
Date

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