1. PERMIT APPLICATION TO DRILL AND OPERATE AN UNCONVENTIONAL WELL

8000-PM-OOGM0001bU Rev. 9/2016
 
 
8000-PM-OOGM0001bU Rev. 5/2017  COMMONWEALTH OF PENNSYLVANIA

 DEPARTMENT OF ENVIRONMENTAL PROTECTION

 OFFICE OF OIL AND GAS MANAGEMENT
 
 
8000-PM-OOGM0001bU Rev. 5/2017
 
 
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
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
     

Zip Code
     

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
 

 

 
 

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:           

    
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 Consent
       
Sent
Return Receipt
   
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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