Form BSEE-0124 "Application for Permit to Modify (Apm)"

This version of the form is not currently in use and is provided for reference only.
Download this version of Form BSEE-0124 for the current year.

What Is Form BSEE-0124?

This is a legal form that was released by the U.S. Department of the Interior - Bureau of Safety and Environmental Enforcement on July 1, 2017 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2017;
  • The latest available edition released by the U.S. Department of the Interior - Bureau of Safety and Environmental Enforcement;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form BSEE-0124 by clicking the link below or browse more documents and templates provided by the U.S. Department of the Interior - Bureau of Safety and Environmental Enforcement.

ADVERTISEMENT
ADVERTISEMENT

Download Form BSEE-0124 "Application for Permit to Modify (Apm)"

884 times
Rate (4.6 / 5) 62 votes
U.S. Department of the Interior
Submit original plus THREE copies, with ONE copy
OMB Control No. 1014-0026
Bureau of Safety and Environmental
marked "Public Information."
OMB Approval Expires 07/31/2020
Enforcement (BSEE)
Application for Permit to Modify (APM)
2. SIDETRACK NO.
1. WELL NAME (CURRENT)
3. BYPASS NO. (CURRENT)
4. OPERATOR NAME and ADDRESS
(CURRENT)
(Submitting office)
5. API WELL NO. (12 digits)
6. START DATE (Proposed)
7. ESTIMATED DURATION (DAYS)
9. If revision, list changes:
8.
Revision
WELL AT TOTAL DEPTH
WELL AT SURFACE
10. LEASE NO.
13. LEASE NO.
11. AREA NAME
14. AREA NAME
12. BLOCK NO.
15. BLOCK NO.
Proposed or Completed Work
16. PRPOSED OR COMPLETED WORK (Describe in Section 17)
PLEASE SELECT ONLY ONE PRIMARY TYPE IN BOLD AND AS MANY SECONDARY TYPES AS NECESSARY.
Completion
Workover:
Enhance Production
Initial Completion
Change Tubing
Acidize
Artificial Lift
Reperforation
Casing Pressure Repair
Wash/Desand Well
Change Zone
Jet Well
Modify Perforations
Abandonment of Well Bore:
Hydraulic Fracturing
Utility
Permanent Abandonment
Initial Injection Well
Temporary Abandonment
Information:
Additional Fluids for Injection
Plugback to Sidetrack/Bypass
Surface Location Plat
Other Operations
Site Clearance
Change Well Name
Describe Operation(s)
17. BRIEFLY DESCRIBE PROPOSED OPERATIONS (Attach prognosis):
. LIST ALL ATTACHMENTS (Attach complete well prognosis and attachments required by 30 CFR 250.465; 250.513(a); 250.513(b); 250.518(f); 250.613(a)
18
through (c); 250.616(a)(4); 250.619(f); 250.701; 250.702; 250.713(a) through (e); 250.713(g); 250.720(b); 250.721(g)(4); 250.731; 250.733(b)(2)(i);
250.734(a)(7); 250.734(b)(1); 250.737(d)(2)(i); 250.737(d)(3)(ii); 250.737(d)(4)(ii); 250.737(d)(12)(i); 250.738(b)(4); 250.738(f); 250.738(i) and (j); 250.738(m)
through (n); 250.738(o); 250.1706(a)(4); 250.1712; 250.1721(a); 250.1721(g); 250.1722(a); 250.1722(d); or 250.1743(a).
19. Rig Name or Primary Unit (e.g., Wireline Unit, Coil Tubing, Snubbing Unit, etc.)
20. The greater of SITP or MASP (psi):
22. SV Depth BML (ft):
21. Type of Safety Valve (SV): _____
SCSSV _____
SSCSV _____
N/A
Rig BOP (Rams)
Rig BOP (Annular)
23.
24.
Size:
Test Pressure
Working Pressure
Test Pressure
Working Pressure
(inches)
(psi)
(psi)
(psi)
(psi)
________
Low/High: ________
_________
Low/High: _________
___________
BSEE
Form BSEE-0124
Page 1 of 3
(July 2017 - Supersedes all previous versions of this form which may not be used.)
U.S. Department of the Interior
Submit original plus THREE copies, with ONE copy
OMB Control No. 1014-0026
Bureau of Safety and Environmental
marked "Public Information."
OMB Approval Expires 07/31/2020
Enforcement (BSEE)
Application for Permit to Modify (APM)
2. SIDETRACK NO.
1. WELL NAME (CURRENT)
3. BYPASS NO. (CURRENT)
4. OPERATOR NAME and ADDRESS
(CURRENT)
(Submitting office)
5. API WELL NO. (12 digits)
6. START DATE (Proposed)
7. ESTIMATED DURATION (DAYS)
9. If revision, list changes:
8.
Revision
WELL AT TOTAL DEPTH
WELL AT SURFACE
10. LEASE NO.
13. LEASE NO.
11. AREA NAME
14. AREA NAME
12. BLOCK NO.
15. BLOCK NO.
Proposed or Completed Work
16. PRPOSED OR COMPLETED WORK (Describe in Section 17)
PLEASE SELECT ONLY ONE PRIMARY TYPE IN BOLD AND AS MANY SECONDARY TYPES AS NECESSARY.
Completion
Workover:
Enhance Production
Initial Completion
Change Tubing
Acidize
Artificial Lift
Reperforation
Casing Pressure Repair
Wash/Desand Well
Change Zone
Jet Well
Modify Perforations
Abandonment of Well Bore:
Hydraulic Fracturing
Utility
Permanent Abandonment
Initial Injection Well
Temporary Abandonment
Information:
Additional Fluids for Injection
Plugback to Sidetrack/Bypass
Surface Location Plat
Other Operations
Site Clearance
Change Well Name
Describe Operation(s)
17. BRIEFLY DESCRIBE PROPOSED OPERATIONS (Attach prognosis):
. LIST ALL ATTACHMENTS (Attach complete well prognosis and attachments required by 30 CFR 250.465; 250.513(a); 250.513(b); 250.518(f); 250.613(a)
18
through (c); 250.616(a)(4); 250.619(f); 250.701; 250.702; 250.713(a) through (e); 250.713(g); 250.720(b); 250.721(g)(4); 250.731; 250.733(b)(2)(i);
250.734(a)(7); 250.734(b)(1); 250.737(d)(2)(i); 250.737(d)(3)(ii); 250.737(d)(4)(ii); 250.737(d)(12)(i); 250.738(b)(4); 250.738(f); 250.738(i) and (j); 250.738(m)
through (n); 250.738(o); 250.1706(a)(4); 250.1712; 250.1721(a); 250.1721(g); 250.1722(a); 250.1722(d); or 250.1743(a).
19. Rig Name or Primary Unit (e.g., Wireline Unit, Coil Tubing, Snubbing Unit, etc.)
20. The greater of SITP or MASP (psi):
22. SV Depth BML (ft):
21. Type of Safety Valve (SV): _____
SCSSV _____
SSCSV _____
N/A
Rig BOP (Rams)
Rig BOP (Annular)
23.
24.
Size:
Test Pressure
Working Pressure
Test Pressure
Working Pressure
(inches)
(psi)
(psi)
(psi)
(psi)
________
Low/High: ________
_________
Low/High: _________
___________
BSEE
Form BSEE-0124
Page 1 of 3
(July 2017 - Supersedes all previous versions of this form which may not be used.)
Submit original plus THREE copies, with ONE copy marked "Public Information."
Application for Permit to Modify (APM) (con't) page 2
Coiled Tubing BOP:
Snubbing Unit BOP:
25.
Wireline Lubricator:
26.
27
Working Pressure
Test Pressure
Test Pressure
BOP Test Pressure
Working Pressure
Working Pressure
(psi)
(psi)
(psi)
(psi)
(psi)
(psi)
____________
Low/High: ________
____________
Low/High: __________
Low/High: _________
_________
This is space is currently blank
29. CONTACT NAME:
30. CONTACT TELEPHONE NO.:
31. CONTACT E-MAIL ADDRESS:
32. AUTHORIZING OFFICIAL (Type or print name)
33. TITLE
34. AUTHORIZING SIGNATURE
35. DATE
THIS SPACE FOR BSEE USE ONLY
APPROVED BY:
TITLE
DATE
36.
Questions
Response
Remarks
YES
A) Is H
S present in the well? If yes,
2
NO
then comment on the inclusion of a
Contingency Plan for this operation.
N/A
YES
B) Is this proposed operation the only
NO
lease holding activity for the subject
lease? If yes, then comment.
N/A
YES
C) Will all wells in the well bay and
related production equipment be shut-in
NO
when moving on to or off of an offshore
platform, or from well to well on the
N/A
platform? If not, please explain.
YES
D) If sands are to be commingled for
NO
this completion, has approval been
obtained?
N/A
YES
E) Will the completed interval be within
NO
500 feet of a block line? If yes, then
comment.
N/A
YES
F) For permanent abandonment, will
NO
casings be cut 15 feet below the
mudline? If no, then comment.
N/A
BSEE
Form BSEE-0124
Page 2 of 3
(July 2017 - Supersedes all previous versions of this form which may not be used.)
Submit original plus THREE copies, with ONE copy marked "Public Information."
Application for Permit to Modify (APM) (con't) page 3
36) Con't
Questions
Response
Remarks
YES
G) Will you ensure well-control fluids, equipment, and
operations be designed, utilized, maintained, and/or tested
NO
as necessary to control the well in foreseeable conditions
N/A
and circumstances, including subfreezing conditions?
YES
H) Will digital BOP testing be used for this operation? If
NO
"yes", state which version in the comment box?
N/A
I) Is this APM being submitted to remediate sustained
YES
casing pressure (SCP)? If "yes," please specify annulus in
NO
the comment box. If you have been given a
departure/denial for SCP as discussed in
#18,
section
N/A
include in the attachments.
YES
J) Are you pulling tubing and/or casing with a crane? If
"yes," have documentation on how you will verify the load is
NO
free per API RP 2D, Appendix B. This documentation must
be maintained by the lessee at the lessee's field office
nearest the OCS facility or other locations conveniently
N/A
available to BSEE for review, when applicable.
YES
K) Will the proposed operation be covered by an EPA
NO
Discharge Permit? (Please provide permit number
comments for this question).
N/A
YES
L) Will you be using multiple size workstring/ tubing/coil
NO
tubing/snubbing/wireline? If yes, attach a list of all sizes to
N/A
be used including the size, weight, and grade.
YES
M) For both surface and subsea operations, are you
NO
utilizing a dynamically positioned vessel/work boat at any
time during this operation?
N/A
CERTIFICATION: I certify that the information submitted is complete and accurate to the best of my knowledge. I understand that making a false statement
may subject me to criminal penalties under 18 U.S.C. 1001.
Name and Title: _________________________________________ Date: ____________________
PAPERWORK REDUCTION ACT OF 1995(PRA) STATEMENT: The PRA (44 U.S.C. 3501 et seq.) requires us to inform you that we collect this information
to obtain knowledge of equipment and procedures to be used in drilling operations. BSEE uses the information to evaluate, approve, or disapprove adequacy
of equipment and/or procedures to safely perform drilling operations. Responses are mandatory (43 U.S.C. 1334). Propriety data are covered under 30 CFR
250.197. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid
OMB Control Number. Public reporting burden for reviewing the instructions, completing and filling out this form only is estimated to average 1 hour per
response. The burden for the attachments required range from 10 minutes to 1.5 hours depending on the requirement. Direct comments regarding the
burden or any other aspect of this form to the Information Collection Clearance Officer, BSEE, 45600 Woodland Road, Sterling, VA 20166
BSEE
Form BSEE-0124
Page 3 of 3
(July 2017 - Supersedes all previous versions of this form which may not be used.)
Page of 3