Form 85-16-1 "Application for a.p.i. Well Identification Number" - New York

What Is Form 85-16-1?

This is a legal form that was released by the New York State Department of Environmental Conservation - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2022;
  • The latest edition provided by the New York State Department of Environmental Conservation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 85-16-1 by clicking the link below or browse more documents and templates provided by the New York State Department of Environmental Conservation.

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Download Form 85-16-1 "Application for a.p.i. Well Identification Number" - New York

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PRINT
DIVISION OF MINERAL RESOURCES
APPLICATION FOR A.P.I. WELL IDENTIFICATION NUMBER
PRINT OR TYPE IN BLACK INK. THIS DOCUMENT SHOULD BE PRINTED ON LEGAL SIZE PAPER.
DO NOT COMPLETE
DEPARTMENT USE ONLY
DO NOT COMPLETE
A.P.I. NUMBER
31-
-
-
-
Location Verified
Date
/
/
WELL OWNER
Full name of organization or individual
Complete mailing address
Telephone (include area code)
(
)
LOCATION INFORMATION
Town
Quad
Quad section
.
.
Decimal Latitude (NAD 83):
Decimal Longitude (NAD 83):
Check which applies:
Map attached
Description (see below)
Location Description:
WELL INFORMATION
Lease or well name
Well no.
Field name
Target formation
Deepest formation
Type (check one)
Oil
Gas
Injection
Other (specify)
Date drilled (year)
Elevation (ft.)
Depth (ft.)
Producing formation (if known)
CURRENT USE OR REMARKS (attach additional sheets if necessary)
CASING AND CEMENTING (enter known information)
CASING
HOLE
PIPE
CASING DEPTHS
CLASS/TYPE
EST. CEMENT
STRINGS
SIZE
SIZE
SET (TMD)
OF CEMENT
TOP (TMD)
Drive Pipe or Conductor
Surface or Water
Intermediate
Production
Liners
AFFIRMATION AND SIGNATURE
I affirm under penalty of perjury that the information provided in this application is true to the best of my knowledge and belief. By signing this form, I
acknowledge that DEC has the right to enter upon and pass through the property where the well subject to this application is located for the purposes of
inspection of the well and, to the extent necessary, areas adjacent to the well site. I further acknowledge that DEC staff has the right to enter upon and pass
through such property in order to inspect the site, without prior notice, between the hours of 7:00 am and 7:00 pm, Monday through Friday, or any time well-
related activities are ongoing at the site. By signing this form, I further acknowledge under penalty of perjury that DEC’s authority to inspect the well and
adjacent areas remains in effect as long as such well is regulated by DEC. I am aware any false statement made in this application is punishable pursuant to
Section 210.45 of the Penal Law.
Printed or Typed Name of Authorized Representative (see below note)
The use of an electronic signature below indicates the signer’s intent to sign the document and is the legal equivalent of having placed a handwritten
signature on this application.
Signature of Authorized Representative (see below note)
Date
/
/
Note: The Authorized Representative must be listed in Box 7 of the Organizational Report on file with the Division of Mineral Resources.
PAGE 1 of 2
85-16-1 (4/22)
PRINT
DIVISION OF MINERAL RESOURCES
APPLICATION FOR A.P.I. WELL IDENTIFICATION NUMBER
PRINT OR TYPE IN BLACK INK. THIS DOCUMENT SHOULD BE PRINTED ON LEGAL SIZE PAPER.
DO NOT COMPLETE
DEPARTMENT USE ONLY
DO NOT COMPLETE
A.P.I. NUMBER
31-
-
-
-
Location Verified
Date
/
/
WELL OWNER
Full name of organization or individual
Complete mailing address
Telephone (include area code)
(
)
LOCATION INFORMATION
Town
Quad
Quad section
.
.
Decimal Latitude (NAD 83):
Decimal Longitude (NAD 83):
Check which applies:
Map attached
Description (see below)
Location Description:
WELL INFORMATION
Lease or well name
Well no.
Field name
Target formation
Deepest formation
Type (check one)
Oil
Gas
Injection
Other (specify)
Date drilled (year)
Elevation (ft.)
Depth (ft.)
Producing formation (if known)
CURRENT USE OR REMARKS (attach additional sheets if necessary)
CASING AND CEMENTING (enter known information)
CASING
HOLE
PIPE
CASING DEPTHS
CLASS/TYPE
EST. CEMENT
STRINGS
SIZE
SIZE
SET (TMD)
OF CEMENT
TOP (TMD)
Drive Pipe or Conductor
Surface or Water
Intermediate
Production
Liners
AFFIRMATION AND SIGNATURE
I affirm under penalty of perjury that the information provided in this application is true to the best of my knowledge and belief. By signing this form, I
acknowledge that DEC has the right to enter upon and pass through the property where the well subject to this application is located for the purposes of
inspection of the well and, to the extent necessary, areas adjacent to the well site. I further acknowledge that DEC staff has the right to enter upon and pass
through such property in order to inspect the site, without prior notice, between the hours of 7:00 am and 7:00 pm, Monday through Friday, or any time well-
related activities are ongoing at the site. By signing this form, I further acknowledge under penalty of perjury that DEC’s authority to inspect the well and
adjacent areas remains in effect as long as such well is regulated by DEC. I am aware any false statement made in this application is punishable pursuant to
Section 210.45 of the Penal Law.
Printed or Typed Name of Authorized Representative (see below note)
The use of an electronic signature below indicates the signer’s intent to sign the document and is the legal equivalent of having placed a handwritten
signature on this application.
Signature of Authorized Representative (see below note)
Date
/
/
Note: The Authorized Representative must be listed in Box 7 of the Organizational Report on file with the Division of Mineral Resources.
PAGE 1 of 2
85-16-1 (4/22)
INSTRUCTIONS FOR A.P.I. WELL IDENTIFICATION APPLICATION FORM
The Division of Mineral Resources has developed this form to accommodate newer drilling technologies and to conform to the American
Petroleum Institute’s (API) well identification number system. For a complete description of the API numbering system, visit ESOGIS’s website at
https://esogis.nysm.nysed.gov/Help_API.cfm. Instructions and examples for completing the form are below.
The completed form should be submitted along with any maps to the appropriate Regional office. If you have any questions or need any further
assistance with the forms, please feel free to contact the Regional office responsible for the area where the well is located.
Allegany Office
(716) 372-0645
(Allegany, Cattaraugus, Chautauqua, Erie, Niagara and Wyoming Counties)
Avon Office
(585) 226-5376
(Jefferson, St. Lawrence, Lewis, Oneida, Herkimer, Oswego, Cayuga, Onondaga, Madison, Tompkins,
Cortland, Chenango, Broome, Orleans, Monroe, Wayne, Genesee, Livingston, Ontario, Yates, Seneca,
Steuben, Schuyler, Tioga and Chemung Counties)
Albany Office
(518) 402-8056
(All other counties)
GENERAL
Complete one form for each well which requires an identification number.
WELL OWNER INFORMATION
Please complete this section exactly as it appears on your Organization Report Form (85-15-12). If you have never filed an
Organizational Report, please complete the form included with this package. The form is also available on our website at
www.dec.ny.gov/energy/4761.html.
LOCATION INFORMATION
Town: Enter the town in which the well is located
A
B
C
Quad: Enter the appropriate 7 ½ minute topographic map. By convention, the Division uses the letter
designations A-I for each section. The correct section can be determined by dividing the 7 ½ minute
D
E
F
topographic map into 9 sections along the 2 ½ minute divisions and lettering them from left to right as shown.
G
H
I
Quad Section: Enter the appropriate 7 ½ minute topographic map section.
Decimal Latitude and Decimal Longitude: If known, otherwise leave blank.
Location Description: It is important that we have the correct location of the well, therefore, BE AS ACCURATE AS POSSIBLE WHEN
DESCRIBING THE LOCATION. A map that shows the location in relation to known markers such as roads, town lines, etc. is preferred.
Sections of tax maps, road maps or land surveys also work well. Please indicate the well’s location as accurately as possible on the map,
circle the location and attach the map to your application.
If the location description is used, please describe as accurately as possible the distance in feet North or South and East or West from
known boundaries such as roads, town lines, and so on in the space provided.
WELL INFORMATION
Lease or Well Name: Enter the complete original name associated with the well. If you do not know that name, enter the name by which
you will identify the well in the future.
Well Number: Enter the well number. For example, the first well on the Smith Farm would be the Smith 1, the second well would be the
Smith 2, and so on.
Field Name: If known, otherwise leave blank.
Target Formation: If known, otherwise leave blank.
Deepest Formation: If known, otherwise leave blank.
Type: What the well is being used for, oil production, gas production, injection, etc.
Date Drilled: To the best of your knowledge, enter the year the well was drilled.
Elevation: If known, otherwise leave blank.
Producing Formation: Enter the formation in which it is completed (for instance Chipmunk, Medina, etc.). If not known, leave blank.
CURRENT USE
Please indicate how the well is currently being used. Is it actively producing, inactive or abandoned? If the well is actively producing, how
is the gas or oil used? Does it supply a home? Is it sold? Please put any other information here concerning the well, including who drilled
the well, and if there were any changes made since the original completion.
CASING AND CEMENTING INFORMATION
Enter any known information regarding the casing program and cement data for the well.
SIGNATURE AND DATE
Please sign and date the application and return it with any maps to DEC.
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85-16-1 (4/22)
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