Form MO780-0210 "Oil and Gas Well Extended Shut-In Status Application - Geological Survey Program" - Missouri

What Is Form MO780-0210?

This is a legal form that was released by the Missouri Department of Natural Resources - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2018;
  • The latest edition provided by the Missouri Department of Natural Resources;
  • 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 MO780-0210 by clicking the link below or browse more documents and templates provided by the Missouri Department of Natural Resources.

ADVERTISEMENT
ADVERTISEMENT

Download Form MO780-0210 "Oil and Gas Well Extended Shut-In Status Application - Geological Survey Program" - Missouri

Download PDF

Fill PDF online

Rate (4.5 / 5) 66 votes
MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR OFFICE USE ONLY
GEOLOGICAL SURVEY PROGRAM
PROCESSED BY
DATE RECEIVED
OIL AND GAS WELL EXTENDED SHUT-IN
STATUS APPLICATION
CHECK NUMBER
CHECK AMOUNT
WELL OWNER INFORMATION
NAME OF COMPANY, ORGANIZATION, OR INDIVIDUAL THAT DRILLS, MAINTAINS, OPERATES, OR CONTROLS OIL AND GAS WELLS IN
OPERATOR LICENSE NUMBER
MISSOURI
WELL INFORMATION
PRODUCTION UNIT (LEASE OR SURFACE UNIT NAME)
WELL NUMBER
API NUMBER
TOTAL DEPTH
GROUND ELEVATION
FT.
FT.
WELL USE (SELECT ONE)
LOCATION OF WELLS (NAD83, DECIMAL DEGREES)
Production Well
Other Well Usage
Injection Well
Latitude
Longitude
SPUD DATE
COMPLETION DATE
LAST DATE WELL WAS ACTIVE
HAS THE WELL EVER BEEN SHUT-IN? IF YES, MOST RECENT DATE
No
Yes When ___________________________
DATE LAST MIT PERFORMED ON THIS WELL (AN MIT MAY BE REQUIRED BEFORE APPROVAL.)
IS REQUIRED SIGNAGE INSTALLED
IS REQUIRED SIGNAGE INSTALLED
FOR EACH WELL
FOR TANK BATTERY
Yes
No
Yes
No
WELL CONSTRUCTION
TYPE OF WELL COMPLETION
Open Hole Interval Information
Open Hole
Open Hole Top
Open Hole Bottom
Geologic Stratum Name (use Missouri Nomenclature)
Perforated Casing
Perforation Information
Perforation Top
Perforation Bottom
Geologic Stratum Name (use Missouri Nomenclature)
SHUT-IN SPECIFICATIONS
Proposed shut-in period (up to one year)
Start Date
End Date
REASON FOR EXTENDED SHUT-IN STATUS
EXTENDED SHUT-IN PLAN (ATTACH A WRITTEN PLAN FOR EACH LEASE WHICH DESCRIBES HOW YOU PROPOSE TO OPERATE, MONITOR OR WINTERIZE THE LEASE AND WELLS
WHILE IN EXTENDED SHUT-IN STATUS)
METHOD OF PAYMENT
TOTAL AMOUNT DUE
Check or Money Order (Please enclose check, payable to Department of Natural Resources, with submitted form.)
Credit Card (Transaction fee applies.) (Please attach contact information of person authorized to make transaction.)
$25
Automated Clearing House (Please attach contact information of person authorized to make transaction.)
CERTIFICATION
I, the undersigned, certify that:
I am authorized to act as the well owner’s agent for the submission of this application
The information on this application has been reviewed by me and is true, correct and complete to the best of my knowl
I understand this extension, if approved, is not transferable to another party or locatio
I understand that this extension must be renewed before the expiration date in order to comply with shut-in well requirements set forth in the Miss
Code of State Regulations Oil and Gas Council Rule 10 CSR 50-2.060.
NAME (PRINT)
TITLE
COMPANY
PRIMARY PHONE NUMBER WITH AREA CODE
EMAIL ADDRESS
SIGNATURE
DATE
FOR OFFICE USE ONLY
Approved shut-in period
Start Date
End Date
APPROVED BY
DATE
MO 780-0210 (9-18) SEND COMPLETED FORM ALONG WITH $25 FEE (PER WELL) TO: MISSOURI DEPARTMENT OF NATURAL RESOURCES, MISSOURI GEOLOGICAL SURVEY,
GEOLOGIC RESOURCES SECTION, PO BOX 250, ROLLA, MO 65402-0250 PHONE: 573-368-2100 FAX: 573-368-2111 EMAIL:
oilandgas@dnr.mo.gov
MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR OFFICE USE ONLY
GEOLOGICAL SURVEY PROGRAM
PROCESSED BY
DATE RECEIVED
OIL AND GAS WELL EXTENDED SHUT-IN
STATUS APPLICATION
CHECK NUMBER
CHECK AMOUNT
WELL OWNER INFORMATION
NAME OF COMPANY, ORGANIZATION, OR INDIVIDUAL THAT DRILLS, MAINTAINS, OPERATES, OR CONTROLS OIL AND GAS WELLS IN
OPERATOR LICENSE NUMBER
MISSOURI
WELL INFORMATION
PRODUCTION UNIT (LEASE OR SURFACE UNIT NAME)
WELL NUMBER
API NUMBER
TOTAL DEPTH
GROUND ELEVATION
FT.
FT.
WELL USE (SELECT ONE)
LOCATION OF WELLS (NAD83, DECIMAL DEGREES)
Production Well
Other Well Usage
Injection Well
Latitude
Longitude
SPUD DATE
COMPLETION DATE
LAST DATE WELL WAS ACTIVE
HAS THE WELL EVER BEEN SHUT-IN? IF YES, MOST RECENT DATE
No
Yes When ___________________________
DATE LAST MIT PERFORMED ON THIS WELL (AN MIT MAY BE REQUIRED BEFORE APPROVAL.)
IS REQUIRED SIGNAGE INSTALLED
IS REQUIRED SIGNAGE INSTALLED
FOR EACH WELL
FOR TANK BATTERY
Yes
No
Yes
No
WELL CONSTRUCTION
TYPE OF WELL COMPLETION
Open Hole Interval Information
Open Hole
Open Hole Top
Open Hole Bottom
Geologic Stratum Name (use Missouri Nomenclature)
Perforated Casing
Perforation Information
Perforation Top
Perforation Bottom
Geologic Stratum Name (use Missouri Nomenclature)
SHUT-IN SPECIFICATIONS
Proposed shut-in period (up to one year)
Start Date
End Date
REASON FOR EXTENDED SHUT-IN STATUS
EXTENDED SHUT-IN PLAN (ATTACH A WRITTEN PLAN FOR EACH LEASE WHICH DESCRIBES HOW YOU PROPOSE TO OPERATE, MONITOR OR WINTERIZE THE LEASE AND WELLS
WHILE IN EXTENDED SHUT-IN STATUS)
METHOD OF PAYMENT
TOTAL AMOUNT DUE
Check or Money Order (Please enclose check, payable to Department of Natural Resources, with submitted form.)
Credit Card (Transaction fee applies.) (Please attach contact information of person authorized to make transaction.)
$25
Automated Clearing House (Please attach contact information of person authorized to make transaction.)
CERTIFICATION
I, the undersigned, certify that:
I am authorized to act as the well owner’s agent for the submission of this application
The information on this application has been reviewed by me and is true, correct and complete to the best of my knowl
I understand this extension, if approved, is not transferable to another party or locatio
I understand that this extension must be renewed before the expiration date in order to comply with shut-in well requirements set forth in the Miss
Code of State Regulations Oil and Gas Council Rule 10 CSR 50-2.060.
NAME (PRINT)
TITLE
COMPANY
PRIMARY PHONE NUMBER WITH AREA CODE
EMAIL ADDRESS
SIGNATURE
DATE
FOR OFFICE USE ONLY
Approved shut-in period
Start Date
End Date
APPROVED BY
DATE
MO 780-0210 (9-18) SEND COMPLETED FORM ALONG WITH $25 FEE (PER WELL) TO: MISSOURI DEPARTMENT OF NATURAL RESOURCES, MISSOURI GEOLOGICAL SURVEY,
GEOLOGIC RESOURCES SECTION, PO BOX 250, ROLLA, MO 65402-0250 PHONE: 573-368-2100 FAX: 573-368-2111 EMAIL:
oilandgas@dnr.mo.gov