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

8000-PM-OOGM0001a Rev. 5/2012
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OFFICE OF OIL AND GAS MANAGEMENT
- 1 -
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 7½’
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?

8000-PM-OOGM0001a Rev. 5/2012
- 2 -
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 5500-PM-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 H
2
S 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:

8000
-
PM
-
OOGM0001a Rev. 5/2012
COMMONWEALTH OF PENNSYLVANIA
Record of Notification / Written Consent
DEPARTMENT OF ENVIRONMENTAL PROTECTOIN
OFFICE OF OIL AND GAS MANAGEMENT
-
3
-
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 1
000
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
<
1
000'
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 2
00 feet
Building
within 2
00 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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