Form OG-14 Application for Vacuum Permit - Illinois

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ILLINOIS DEPARTMENT OF NATURAL RESOURCES
Office of Oil and Gas
One Natural Resources W ay
Springfield, Illinois 62702-1271
(217) 782-7756
OG-14
APPLICATION FOR VACUUM PERMIT
PERM ITTEE: ____________________________________________________ PERM ITTEE #: ________________
W ELL NAM E: _________________________________________________________________________________
REFERENCE #: _____________________________________ PERM IT #: ________________________________
LOCATION OF W ELL:
_______ FT. NORTH: OR _______ FT. SOUTH; AND _______ FT. EAST; OR _______ FT. W EST OF THE
_______ CORNER OF THE _______ QUARTER OF THE _______ QUARTER OF THE _______ QUARTER
OF SECTION _______, TOW NSHIP _______ (NORTH/SOUTH), RANGE _______ (EAST/W EST) OF
__________________COUNTY, ILLINOIS
ZONES SUBJECT TO VACUUM:
FORM ATION: _________________________________ FROM: _____________FT
TO ______________FT
FORM ATION: _________________________________ FROM: _____________FT
TO ______________FT
FORM ATION: _________________________________ FROM: _____________FT
TO ______________FT
FORM ATION: _________________________________ FROM: _____________FT
TO ______________FT
FORM ATION: _________________________________ FROM: _____________FT
TO ______________FT
FORM ATION: _________________________________ FROM: _____________FT
TO ______________FT
THE PERMITTEE LISTED ABOVE IS REQUESTING A PERMIT TO APPLY VACUUM TO THE ABOVE LISTED
W ELL AND FORMATION(S). THE PERMITTEE IS HEREBY AFFIRMING THAT ALL PERSONS OW NING OR
MANAGING PRODUCING OIL OR GAS W ELLS W ITHIN ONE-QUARTER MILE (AS SHOW N ON THE PLAT
ON THE BACK OF THIS FORM) OF THE PROPOSED VACUUM W ELL HAVE BEEN NOTIFIED BY CERTIFIED
MAIL, RETURN RECEIPT REQUESTED, OF THE LEGAL LOCATION O F THE PROPOSED W ELL AND THE
NAME AND DEPTH OF THE PROPOSED STRATA OR FORMATION TO BE AFFECTED BY THE USE OF SUCH
VACUUM. ( A COPY OF THE NOTICE AND PROOF OF MAILING IS REQUIRED TO BE SUBMITTED W ITH
THIS APPLICATION).
NAME OF APPLICANT (PLEASE PRINT )
__________________________________________________
_____________________________________
SIGNATURE
TITLE
__________________________________________________
____________________________________
ADDRESS
DATE
__________________________________________________
CITY
STATE
ZIP
T HIS ST A TE A G E NC Y IS REQ1UESTIN G D ISC LO SU RE O F IN FO RM A T IO N TH AT IS N E CE SSARY T O A C C O M PLISH T HE STA T UT OR Y PU RPO SE AS
O U TLIN ED IN THE ILL. C O M PILED STATE, C H. 225, PAR S. 725 ET.SEQ . FAILU R E TO D ISC LO SE THIS IN FO R M ATIO N W ILL R ESU LT IN THIS FO R M N O T
BEIN G PR O C ESSED . THIS FO R M HAS BEEN APPR O V ED BY THE FO R M S M AN AG EM EN T C EN TER .
ILLINOIS DEPARTMENT OF NATURAL RESOURCES
Office of Oil and Gas
One Natural Resources W ay
Springfield, Illinois 62702-1271
(217) 782-7756
OG-14
APPLICATION FOR VACUUM PERMIT
PERM ITTEE: ____________________________________________________ PERM ITTEE #: ________________
W ELL NAM E: _________________________________________________________________________________
REFERENCE #: _____________________________________ PERM IT #: ________________________________
LOCATION OF W ELL:
_______ FT. NORTH: OR _______ FT. SOUTH; AND _______ FT. EAST; OR _______ FT. W EST OF THE
_______ CORNER OF THE _______ QUARTER OF THE _______ QUARTER OF THE _______ QUARTER
OF SECTION _______, TOW NSHIP _______ (NORTH/SOUTH), RANGE _______ (EAST/W EST) OF
__________________COUNTY, ILLINOIS
ZONES SUBJECT TO VACUUM:
FORM ATION: _________________________________ FROM: _____________FT
TO ______________FT
FORM ATION: _________________________________ FROM: _____________FT
TO ______________FT
FORM ATION: _________________________________ FROM: _____________FT
TO ______________FT
FORM ATION: _________________________________ FROM: _____________FT
TO ______________FT
FORM ATION: _________________________________ FROM: _____________FT
TO ______________FT
FORM ATION: _________________________________ FROM: _____________FT
TO ______________FT
THE PERMITTEE LISTED ABOVE IS REQUESTING A PERMIT TO APPLY VACUUM TO THE ABOVE LISTED
W ELL AND FORMATION(S). THE PERMITTEE IS HEREBY AFFIRMING THAT ALL PERSONS OW NING OR
MANAGING PRODUCING OIL OR GAS W ELLS W ITHIN ONE-QUARTER MILE (AS SHOW N ON THE PLAT
ON THE BACK OF THIS FORM) OF THE PROPOSED VACUUM W ELL HAVE BEEN NOTIFIED BY CERTIFIED
MAIL, RETURN RECEIPT REQUESTED, OF THE LEGAL LOCATION O F THE PROPOSED W ELL AND THE
NAME AND DEPTH OF THE PROPOSED STRATA OR FORMATION TO BE AFFECTED BY THE USE OF SUCH
VACUUM. ( A COPY OF THE NOTICE AND PROOF OF MAILING IS REQUIRED TO BE SUBMITTED W ITH
THIS APPLICATION).
NAME OF APPLICANT (PLEASE PRINT )
__________________________________________________
_____________________________________
SIGNATURE
TITLE
__________________________________________________
____________________________________
ADDRESS
DATE
__________________________________________________
CITY
STATE
ZIP
T HIS ST A TE A G E NC Y IS REQ1UESTIN G D ISC LO SU RE O F IN FO RM A T IO N TH AT IS N E CE SSARY T O A C C O M PLISH T HE STA T UT OR Y PU RPO SE AS
O U TLIN ED IN THE ILL. C O M PILED STATE, C H. 225, PAR S. 725 ET.SEQ . FAILU R E TO D ISC LO SE THIS IN FO R M ATIO N W ILL R ESU LT IN THIS FO R M N O T
BEIN G PR O C ESSED . THIS FO R M HAS BEEN APPR O V ED BY THE FO R M S M AN AG EM EN T C EN TER .
OUTLINE YOUR LEASE AND DRILLING UNIT BOUNDARIES BELOW AND SPOT W ELL SUBJECT TO
VACUUM AND ALL OFFSET W ELLS.
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