DEP Oil&Gas Form 3 "Application for Permit to Drill" - Florida

DEP Form Oil&Gas3 or the "Application For Permit To Drill" is a form issued by the Florida Department of Environmental Protection.

Download a PDF version of the DEP Form Oil&Gas3 down below or find it on the Florida Department of Environmental Protection Forms website.

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Download DEP Oil&Gas Form 3 "Application for Permit to Drill" - Florida

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Oil & Gas Form 3
Florida
APPLICATION FOR PERMIT TO DRILL
Form Title:
Department of
Date Revised:
April 22, 2014
Environmental Protection
Incorporated by Reference in:
Section 62C-25.006(4)(a), F.A.C.
For information and fees regarding drilling permits for oil and gas related wells, refer to Chapter 62C-26, Florida Administrative
Code. File this form with the Florida Department of Environmental Protection, Oil and Gas Program, 2600 Blair Stone Road, MS
3588, Tallahassee, Florida 32399-2400; (phone 850-245-8336) or, Email:
OGP@dep.state.fl.us
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
(Company’s Name and Address)
Phone Number: _____________________________________ Fax Number: ____________________________________
Well Name and Number: ________________________________________________________________________________
Ground Elevation: _______________ Acres Assigned to Well: _________ Latitude: __________ Longitude: ___________
SHL: ___________________________________________________________ Sec. __________ T. _________ R. _______
BHL: ___________________________________________________________ Sec. __________ T. _________ R. _______
Field/Area: ____________________________________________________________ County: _______________________
Distance to nearest drilling unit boundary: ____________________________________ Proposed Depth: _______________
Do you have all of the mineral interest in the drilling unit under lease or title? ____________ (Yes or No) If not, attach lease
map showing ownership of all mineral acreage within the drilling unit and list the names and addresses of all nonconsenting
mineral owners. (See section 377.2411 and .247, Florida Statutes.)
Is the structure intended for the drilling or production of this well located (See section 377.24, F. S.)
(Please answer YES or NO)
a) in a municipality?
_________
b) in tidal waters within 3 miles of a municipality?
_________
c) on an improved beach?
_________
d) on any submerged land within a bay, estuary, or offshore waters?
_________
e) within one mile seaward of the coastline of the state?
_________
f) within one mile seaward of the boundary of a local, state or federal park or an aquatic or wildlife
preserve?
_________
g) On the surface of a freshwater lake, river or stream?
_________
h) within one mile inland from the shoreline of the Gulf of Mexico, the Atlantic Ocean
or any bay or estuary?
_________
i) within one mile of any freshwater lake, river or stream?
_________
If the answer to a, b, or c is YES, attach copies of local governing authorities’ permits. If the answer to h or i is YES, attach a
contingency plan specifying safeguards being implemented to prevent accidents and/or blowouts and to protect the natural
resources of such bodies of water and shore areas in the event of an accident or blowout.
The security for this well is ___________________ (attached or on file) with the Oil and Gas Program (see Rule 62C-26.002)
and bears Serial Number ______________________________.
================================================================================================
Company’s Statement
State: _________________________________
County: _______________________________
I, ____________________________________________, am the ________________________________________________
(Name)
( Title)
of ____________________________________________ and attest to all information contained herein to be true and correct.
(Organization)
Signature: _________________________________ Residential Address:
____________________________________
Date: _____________________________________ City/State/Zip:
____________________________________
================================================================================================
File Number: ____________ Action: ________________ Date: _______________ A.P. I. Number: _________________
(Approved, Denied)
Oil & Gas Form 3
Florida
APPLICATION FOR PERMIT TO DRILL
Form Title:
Department of
Date Revised:
April 22, 2014
Environmental Protection
Incorporated by Reference in:
Section 62C-25.006(4)(a), F.A.C.
For information and fees regarding drilling permits for oil and gas related wells, refer to Chapter 62C-26, Florida Administrative
Code. File this form with the Florida Department of Environmental Protection, Oil and Gas Program, 2600 Blair Stone Road, MS
3588, Tallahassee, Florida 32399-2400; (phone 850-245-8336) or, Email:
OGP@dep.state.fl.us
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
(Company’s Name and Address)
Phone Number: _____________________________________ Fax Number: ____________________________________
Well Name and Number: ________________________________________________________________________________
Ground Elevation: _______________ Acres Assigned to Well: _________ Latitude: __________ Longitude: ___________
SHL: ___________________________________________________________ Sec. __________ T. _________ R. _______
BHL: ___________________________________________________________ Sec. __________ T. _________ R. _______
Field/Area: ____________________________________________________________ County: _______________________
Distance to nearest drilling unit boundary: ____________________________________ Proposed Depth: _______________
Do you have all of the mineral interest in the drilling unit under lease or title? ____________ (Yes or No) If not, attach lease
map showing ownership of all mineral acreage within the drilling unit and list the names and addresses of all nonconsenting
mineral owners. (See section 377.2411 and .247, Florida Statutes.)
Is the structure intended for the drilling or production of this well located (See section 377.24, F. S.)
(Please answer YES or NO)
a) in a municipality?
_________
b) in tidal waters within 3 miles of a municipality?
_________
c) on an improved beach?
_________
d) on any submerged land within a bay, estuary, or offshore waters?
_________
e) within one mile seaward of the coastline of the state?
_________
f) within one mile seaward of the boundary of a local, state or federal park or an aquatic or wildlife
preserve?
_________
g) On the surface of a freshwater lake, river or stream?
_________
h) within one mile inland from the shoreline of the Gulf of Mexico, the Atlantic Ocean
or any bay or estuary?
_________
i) within one mile of any freshwater lake, river or stream?
_________
If the answer to a, b, or c is YES, attach copies of local governing authorities’ permits. If the answer to h or i is YES, attach a
contingency plan specifying safeguards being implemented to prevent accidents and/or blowouts and to protect the natural
resources of such bodies of water and shore areas in the event of an accident or blowout.
The security for this well is ___________________ (attached or on file) with the Oil and Gas Program (see Rule 62C-26.002)
and bears Serial Number ______________________________.
================================================================================================
Company’s Statement
State: _________________________________
County: _______________________________
I, ____________________________________________, am the ________________________________________________
(Name)
( Title)
of ____________________________________________ and attest to all information contained herein to be true and correct.
(Organization)
Signature: _________________________________ Residential Address:
____________________________________
Date: _____________________________________ City/State/Zip:
____________________________________
================================================================================================
File Number: ____________ Action: ________________ Date: _______________ A.P. I. Number: _________________
(Approved, Denied)
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