1. PERMIT APPLICATION TO DRILL AND OPERATE A CONVENTIONAL WELL

8000-PM-OOGM0001a 3/2012
 
 
8000-PM-OOGM0001a Rev. 5/2012  COMMONWEALTH OF PENNSYLVANIA

 DEPARTMENT OF ENVIRONMENTAL PROTECTION

 OFFICE OF OIL AND GAS MANAGEMENT
 
 
8000-PM-OOGM0001a Rev. 5/2012
 
 
8000-PM-OOGM0001a Rev. 5/2012  COMMONWEALTH OF PENNSYLVANIA
Record of Notification / Written Consent  DEPARTMENT OF ENVIRONMENTAL PROTECTOIN

 OFFICE OF OIL AND GAS MANAGEMENT

 



PERMIT APPLICATION TO DRILL AND OPERATE A CONVENTIONAL WELL
DEP USE ONLY
Notes OGO #

     

Objection Date - Do not issue before:
 
     
API #’s37-    -       -    -    ;

and -    -    ; -    -    ; -    -    ; -    -    ; -    -   

Client Id       Date Approved:
      Bond #             Watershed Name:      
Designation:   HQ   EV
C:         G:       Special Cond.      
INV:      
  APS #       Auth Id       Site Id       PF Id       SF Id        
Please read instructions before you begin filling in this form.
WELL INFORMATION
Well Operator
     
DEP ID#
     
Well API #
37-    -     -  -  
Well Farm Name
     
Well #
     
Address
     
LAT     °   ׳    ״ NAD 83 Project Number
     
Serial #
     
LONG -     °   ׳    ״
City
     
State
     
Zip
     
Municipality Name/ City, Borough, Township
             
County
     
Phone
     
Fax
     
Email
     
USGS 7.5 min. quadrangle map
       
Section
 
Check if this is a new address
24/7 Emergency Phone contact number
     
 
911 address of well site (if available)
     
Freshwater Impoundment Name/ Identification       Centralized Impoundment Name/ Identification       Well Pad Name/Identification
     
Borrow Area Name/Identification
     
Surface Elev
     
Deepest Formation to be penetrated:
     
Anticipated TVD
     
PERMIT TYPE

Check applicable.

Application is to:

Drill a new

Re-permit expired permit

Deepen well

Redrill wellbore

Alter well

Other (specify)

     

TYPE OF WELL

Check applicable.

Gas

Oil

Comb. (gas & oil/condensate)

Injection, recovery

Injection, disposal

Coalbed Methane

Gas Storage

Other (specify )

     

 

Configuration

Vertical

Horizontal

Deviated

Multiple laterals

APPLICATION FEE

Check applicable.

Conventional

$200 (Home Use Well)

 

Total Application Fee $        

 

 

 

 

Bond Agreement Id

     

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.
If applying for a permit to rework an existing well not registered or permitted, check this box and enter date drilled, if known:         (see instructions)
PNDI Attached : Any threatened or endangered “hit” must include a copy of the clearance letter from the applicable agency(ies).
Application submitted as:   Coal well: Attach Coal Module
  CBM 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 edge of the disturbed area of any portion of the well site of a conventional well be within 100 feet from the edge of any solid blue lined stream, spring or body of water identified on the most current 7 ½ ’ topographic quadrangle map or wetland greater than one acre in size or in a wetland?
If yes, is a waiver request (form 5500-FM-OG0057) and site-specific E&S control plan attached?
 

 
   
3.  Will the well penetrate or be within 2,000 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 well be drilled within 200 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?
6.  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 5500PM-OG0076? If yes, attach a competed copy of the form and clearance letters from applicable agencies.
7.  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 stream        .

7.1  Will the well be drilled using enhanced drilling or completion technologies into a formation that typically produces gas or petroleum?
8.  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.      
8.1  Is the disturbed area of the well site between 1 to 5 acres and in a Special Protection Watershed
9.  Is waste, including drill cuttings, from the drilling of this well is to be disposed of on this well site? Yes   No  
10.  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. Yes   No

  a.  If yes, is a waiver request attached that will protect the Waters of the Commonwealth? Yes   No

11.  Is the well to be located within a H2S area pursuant to §78.77a? Yes   No
12.  Attach a current Ownership & Control form 8000-FM-OOGM0118.  
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
A CONVENTIONAL WELL
Record of Notification
Farm Name - Well #
     
Applicant Name  DEP ID#
             
DEP USE ONLY
APS #
     
List the following: surface landowner; surface landowners and water purveyors with water supplies within 1000 feet; municipality where the well will be drilled; adjacent municipality; gas storage operator if within 2000 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 <1000'
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 200 feet
Building within 200 feet
Print and Sign Name: Address: Date      
Print and Sign Name: Address: Date:      
Print and Sign Name: Address: Date:      
Print and Sign Name: Address: Date:      
Print and Sign Name: Address: Date:      

 

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