1. PERMIT APPLICATION TO DRILL AND OPERATE AN UNCONVENTIONAL WELL
      2. WELL INFORMATION
      3. PERMIT APPLICATION TO DRILL AND OPERATE
      4. AN UNCONVENTIONAL WELL
    1. Record of Notification
    2. Record of Written Consent

8000-PM-OOGM0001bU Rev. 5/2017
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OFFICE OF OIL AND GAS MANAGEMENT
- 1 -
PERMIT APPLICATION TO DRILL AND OPERATE AN UNCONVENTIONAL WELL
Please read instructions before you begin filling in this form.
WELL INFORMATION
Well Operator
DEP ID#
Well API No.
37-
-
-
-
Well Farm Name
Well #
Address
LAT
.
NAD
83
Project Number
Serial #
LONG -
.
City
State
ZipCode
Municipality Name/ City, Borough, Township
/
County
Phone No.
Fax No.
Email
USGS 7.5 min. quadrangle map
Section
24/7 Emergency Phone Contact No.:
ESGP Permit No.
Well Pad (cluster) Name/Identification
911 address of well site (if available)
Surface Elev.
Deepest Formation to be Penetrated
Anticipated TVD
PERMIT TYPE
Check applicable.
Application is to
Modify existing
well/permit
TYPE OF WELL
Check applicable.
Gas
Comb. (gas &
oil/condensate)
APPLICATION FEE
Check applicable.
Vertical
Non-vertical
Total Application Fee
$
Target Formation(s) Proposed for Production
,
,
,
Anticipated Target Top/Bottom TVD
/
Number of wellbore laterals proposed under this application
.
Total feet of wellbore to be drilled under this application
Ft.
Configuration
Vertical
Horizontal
Deviated
Multiple
laterals
PNDI Attached
:
Any threatened or endangered “hit” must include a demonstration of how the impact will be
avoided or minimized and mitigated, or justification that section 78a.15(e) applies.
Bond Agreement
Id:
Application submitted as:
Coal well (Attach Coal Module)
Non coal well (Attach justification)
COORDINATION WITH REGULATIONS AND OTHER PERMITS
Yes
No
1. Will the well be subject to the
Oil and Gas Conservation Law
? If “No,” go to 2).
a. If “Yes” to #1, is the well at least 330 feet from outside lease or unit boundary?
b. Does the location fall within an area covered by a spacing order?
c. If the well will be multilateral, identify the wellbores on the sketch on page 3 of the plat that will be completed as
conservation and non-conservation.
2. Will the proposed limit of disturbance of the well site be within 100 feet measured horizontally form any watercourse
or any high quality of exceptional value body of water or any wetland one acre or greater in size?
If yes, attach the following if applicable: a site-specific E&S control plan, a permit consistent with Chapter 102,
applicable portions of the Pollution Prevention Control Plan, applicable portions of the Well Site Emergency
Response Plan, applicable portions of the Site Containment Plan, the permit number of a Water Obstruction and
Encroachment Permit issued pursuant to Chapter 105, or justification that section 78a.15(e) applies.
Will the well or well site 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.
If yes, attach a plan that identifies the additional measure, facilities or practices to be employed during well site
construction, drilling and operations to protect the waters of the Commonwealth

8000-PM-OOGM0001bU
Rev. 5/2017
- 2 -
COORDINATION WITH REGULATIONS AND OTHER PERMITS (cont’d)
Yes
No
3.
Will the vertical wellbore section penetrate or be within 3,000 feet of an active
gas storage reservoir
boundary?
a.
If Yes, print the names of:
Storage Field:
Operator:
4.
Is the proposed well location within the permitted area of a
landfill
?
5.
Will the vertical wellbore section of the unconventional well be drilled within 500 feet from any existing building or
an existing water supply?
a.
If “Yes,” is written consent from the owner attached?
b.
If written consent is not attached, is a variance request (form 8000-FM-OOGM0058) attached?
5.1. Will the vertical wellbore of the unconventional well be drilled within 1,000 feet from any existing water well, surface
water intake, reservoir or other water supply extraction point used by a water purveyor?
a.
If “Yes,” is written consent from the owner attached?
b.
If written consent is not attached, is a variance request (form 8000-FM-OOGM0058) attached?
6.
Is this permit application for a well that will be drilled on a well site for which construction was completed prior to
April 16, 2012?
a.
If “Yes,” was there a permitted well at this well site prior to April 16, 2012?
b.
If the answer to question no. 6a is “Yes”, provide the US Well Number (API No.) of the well permitted at this
site prior to April 16, 2012.
7.
Will the well be located where it may impact a public resource as outlined in the “Coordination of a Well Location
with Public Resources” form 8000-PM-OOGM0076? If yes, attach a completed copy of the form.
8.
Will any portion of the well site be in a Special Protection High Quality
(HQ) or Exceptional Value
(EV)
watershed?
Provide name of special protection watershed
.
9.
Is this well part of a development which requires an Earth Disturbance Permit for Oil and Gas Activities disturbing
more than 5 acres? If yes, list the number of the ESCGP approval if the permit has been issued.
If no, is this well part of a development that involves 1 to less than 5 acres of earth disturbance over the life of the
project and is the answer to question no. 8 “Yes”? If yes, attach a site-specific E&S control plan.
10. Is the well to be located within a H
2
S area pursuant to §78a.77a?
11. Attach a current Ownership & Control form 8000-FM-OOGM0118 with the first application submitted after the effective date of the final
“Environmental Protection Performance Standards at Oil and Gas Well Sites” rulemaking, or if there have been any changes to parent and
subsidiary business corporations.
Signature of Applicant
The person signing this form attests that they have the authority to submit this application on behalf of the applicant, and that the
information, including all related submissions, is true and accurate to the best of their knowledge.
Signature of Person Authorized to Submit Application
(Print or
Type)
Name of Signer:
Title:
Date
Application Preparer/Contact:
Phone:

8000-PM-OOGM0001bU
Rev. 5/2017
COMMONWEALTH OF PENNSYLVANIA
Record of Notification / Written Consent
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OFFICE OF OIL AND GAS MANAGEMENT
PERMIT APPLICATION TO DRILL AND OPERATE
AN UNCONVENTIONAL WELL
Record of Notification
US Well No. (API No.)
Signature of Applicant
I hereby certify that, for all interested parties identified on the plat of this application for which written consent or an “Affidavit of Non-Delivery of Certified
Mail” has not been uploaded, copies of the well plat have been sent via certified mail and I have received a return receipt verifying delivery.
Signature of Person Authorized to Submit Application
(Print or Type)
Name of Signer:
Title:
Date
List the following: surface landowner; surface landowners and water purveyors with water supplies within 3,000 feet; municipality where the
well will be drilled; adjacent municipality; municipalities within 3,000 feet of the vertical well bore; gas storage operator if within 3,000 feet.
Mark the boxes,
“X
,” which show the parties’ interests. Use additional forms if you need more space. You are required to notify each of
these parties.
Notification: Signature below name indicates the party’s acknowledgement of receipt of the well location
plat and serves as proof of notification
Surface Landowner
Gas Storage Operator
Surface Landowners
& Water Purveyors
with water supplies
<3000'
Municipalities
Notification
Note the means and attach proof.
Certified Mail Dates
Address
Affidavit
Written
Sent
Return Receipt
Consent
Print Name:
Signature
Address:
Print Name:
Signature
Address:
Print Name:
Signature
Address:
Print Name:
Signature
Address:
Print Name:
Signature
Address:
Record of Written Consent
Written Consent: Signature below indicates the party’s approval of the well location, or indicates written consent and waives the 15-day objection period where applicable.
Check applicable box
Surface Owner
Water Well within 500 feet
Building within 500 feet
Print and Sign Name:
Address:
Date
Print and Sign Name:
Address:
Date
Print and Sign Name:
Address:
Date

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