8000-PM-OOGM0001 4/2012  COMMONWEALTH OF PENNSYLVANIA
    Checklist  DEPARTMENT OF ENVIRONMENTAL PROTECTION

     OFFICE OF OIL AND GAS MANAGEMENT

     
     
    CHECKLIST FOR COMPLETING AN APPLICATION FOR A PERMIT TO DRILL, OPERATE OR ALTER
    AN OIL OR GAS WELL
    Farm Name - Well #
         
      Applicant Name  DEP ID#
                
     
    (Forms 8000-PM-OOGM0001 and 8000-PM-OOGM0002)
    DEP USE ONLY
    Auth Id        
    This optional checklist is for your use to help assure that you submit a complete application. Failure to provide all required information will delay processing. Compare your finished application to this list to make sure you include all the required information, forms, and documents. Mark the box in the appropriate column for those items which are attached, or not applicable.
    REQUIREMENT
    Conventional Unconventional
     
    Included
    N/A
    Included
    N/A
    a.   Page 1 with all spaces filled in where applicable.
           
    b.   Page 2, with names, addresses, and signatures (surface owner, water supplies purveyors, coal mines, and gas storage operator municipality and adjacent municipalities).
       
     
     
     
     
    c.   Location plat, form 8000-PM-OOGM0002, Original and one copy
       
     
     
     
     
    d.   Application fee based on permit fee calculator, check or money order payable to “Commonwealth of Pennsylvania.”
           
    e.   Proof and record of notifications and/or written consent, as applicable:

    1.   Attach copies of signed and dated certified mail receipt cards or a completed "Affidavit of Non-Delivery of Certified Mail" as proof that you notified the parties listed on page 2. Note that you are required to send a copy of the whole application (pages 1 and 2 of form 8000PMOOGM0001 as well as the plat, form 8000PMOOGM0002 and attachments). Also, to parties with water supplies within 1,000 or 3,000 feet of the well location as applicable, include “Landowner Notification of Well Drilling or Alterations,” form (8000FMOOGM0052).

           
    2.   For required or optional written consent from a notified party -- is the party’s signature in ink on the appropriate blank on Page 2, or on a separate document.
           
    f.   Bond instrument, if not already in effect
           
    g.   Bond Agreement Id # provided on Page 1 if bond is in effect
           
    h.   For a “Phased Deposit” bond -- additional collateral, if required.
           
    i.   “Coal well” -- spacing exception   request or well cluster spacing.
     
           
    j.  Request for Waiver for Distance Requirements from Springs, Stream, Body of Water, or Wetland, form 8000-FM-OOGM0057.
           
    k.  Request For Variance From Distance Restriction From Existing Building Or Water Supply, form 8000-FM-OOGM0058.
           
    l.  Request For Approval of Alternate Waste Management Practices (form 5500PMOG0071), if needed.
           
    m.  Proposed Alternate Method of Casing, Plugging, Venting or Equipping (form 8000PMOOGM0024), if needed.
           
    n.  Coordination of a Well Location with Public Resources (form 8000PMOOGM0076), if needed.
           
    o.  For a disposal well or an enhanced recovery well, include the additional information required by regulations §78.18 (EPA UIC permit; control and disposal plan; erosion and sedimentation control plan).
           
    p.  Attach a copy of your PNDI check for the proposed well location shown on your plat.
           
    q.  Earth Disturbance Permit: Attached on prior ESCGP approval.
           
    r.  WMP for Unconventional Well: Attached prior approval.
         
    Signature of Applicant
    s.   On page 1 of the application -- the signature, and printed name and title of the person authorized to submit the application, and date. See instructions, SIGNATURE OF APPLICANT.
     
     

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