Form MO780-0211 "Oil and Gas Permit to Drill or Modify Well Application - Geological Survey Program" - Missouri

What Is Form MO780-0211?

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 March 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 MO780-0211 by clicking the link below or browse more documents and templates provided by the Missouri Department of Natural Resources.

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Download Form MO780-0211 "Oil and Gas Permit to Drill or Modify Well Application - Geological Survey Program" - Missouri

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DATE RECEIVED
MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR OFFICE USE ONLY
GEOLOGICAL SURVEY PROGRAM
CHECK NUMBER
CHECK AMOUNT
OIL AND GAS PERMIT TO DRILL OR MODIFY
WELL APPLICATION
PROCESSED BY
PERMIT NUMBER
PERMIT INFORMATION
NAME OF COMPANY, ORGANIZATION, OR INDIVIDUAL THAT DRILLS, MAINTAINS, OPERATES, OR CONTROLS OIL AND GAS WELLS IN MISSOURI OPERATOR LICENSE NUMBER
IS THIS IS A MULTIPLE-COMPLETED WELL
PERMIT TYPE
No
Yes (multiple-completed wells are subject to conditions of 10 CSR 50-2.040(5))
Individual well permit
Blanket well permit
PERMIT INTENT (SELECT ONE)
New well construction
Deepen well
Plug-back well
Recomplete well
Change use of well
Other (explain in comments box below)
WELL INFORMATION
PROPOSED WELL USE (SELECT ONE)
Production Well:
Oil
Commercial gas
Non-commercial gas
Coalbed methane
Injection Well:
Enhanced oil recovery
Disposal of formation fluids
Cyclic steam stimulation
Other (explain in comments box below)
Other Well Usage:
Stratigraphic test
Observation for __________________________________________
Other (explain in comments box below)
WELL ORIENTATION (SELECT ONE)
NUMBER OF ABANDONED
(UNPLUGGED) WELLS ON LEASE
Vertical Well
Proposed depth
_____________ FT.
Plug back depth
____________ FT.
Horizontal Well
Measured vertical depth
_____________ FT.
Horizontal borehole length ____________ FT.
PRODUCTION UNIT (LEASE OR SURFACE UNIT
GEOLOGIC STRATUM NAME (USE MISSOURI
WELL NUMBER
GROUND ELEVATION
API NUMBER (FOR EXISTING
WELL ONLY)
NOMENCLATURE)
NAME)
FT.
BOND INFORMATION
Single well bond
Blanket well bond
On file
Attached
BOND TYPE
BOND STATUS
PROPOSED NEW WELL CONSTRUCTION AND CASING/TUBING SPECIFICATIONS
PLANNED SPUD DATE
PROPOSED DRILLING METHOD
COMMENTS
Coring
Rotary
Casing/Tubing Type
Setting Depth Diameter
Weight/Foot Packer Depth Full Length Cement (If no, explain alternative proposed method)
Yes
No
Yes
No
Yes
No
Yes
No
REQUIRED INFORMATION FOR SUBMISSION
If this permit is approved, you agree to submit all well information obtained including: driller’s log, e-log(s), core analyses, drill stem test, and additional requirements as
indicated below. For new well permit applications, the well location information must be submitted on the back of this form.
METHOD OF PAYMENT
Check or Money Order (Please enclose check, payable to Department of Natural Resources, with submitted form.)
AMOUNT DUE
Credit Card (Transaction fee applies.) (Please attach contact information of person authorized to make transaction.)
$100
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 an agent for the applicant of this well.
 The information on this application has been reviewed by me and is true, correct and complete to the best of my knowledge.
 I understand this permit, if approved, is not transferable to another party or location.
 I understand the submittal fee assessed to this well is non-refundable and non-transferable.
 I understand the submission of this application does not guarantee its approval.
 I understand this application will become null and void if no response has been received after thirty (30) days of notification requesting required missing or incomplete
information, at which time, the applicant may opt to submit a new application and associated fee for review.
 I understand additional requirements, as indicated below, may be a condition for the approval of this permit.
 I understand this permit, if for a single well, is valid for one (1) year after date of approval.
 I agree to abide by Chapter 259, RSMo, and the Missouri Code of State Regulations Oil and Gas Council Rules 10 CSR 50.
 I understand this permit, in no way, relieves me of my obligations to comply with all applicable federal, state and local laws or regulations.
NAME (PRINT)
TITLE
COMPANY
PRIMARY PHONE NUMBER WITH AREA CODE
EMAIL ADDRESS
SIGNATURE
DATE
FOR OFFICE USE ONLY
ADDITIONAL REQUIREMENTS
None
Cuttings on five foot interval
Core
Water sample(s) depth: ______________________________
Other _______________________________
APPROVED BY
APPROVAL DATE
PERMIT EXPIRATION DATE
MO 780-0211 (3-18)
SEND COMPLETED FORM ALONG WITH $100 APPLICATION FEE TO: MISSOURI DEPARTMENT OF NATURAL RESOURCES, MISSOURI GEOLOGICAL SURVEY,
oilandgas@dnr.mo.gov
GEOLOGIC RESOURCES SECTION, PO BOX 250, ROLLA, MO 65402 PHONE: 573-368-2100 FAX: 573-368-2111 EMAIL:
DATE RECEIVED
MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR OFFICE USE ONLY
GEOLOGICAL SURVEY PROGRAM
CHECK NUMBER
CHECK AMOUNT
OIL AND GAS PERMIT TO DRILL OR MODIFY
WELL APPLICATION
PROCESSED BY
PERMIT NUMBER
PERMIT INFORMATION
NAME OF COMPANY, ORGANIZATION, OR INDIVIDUAL THAT DRILLS, MAINTAINS, OPERATES, OR CONTROLS OIL AND GAS WELLS IN MISSOURI OPERATOR LICENSE NUMBER
IS THIS IS A MULTIPLE-COMPLETED WELL
PERMIT TYPE
No
Yes (multiple-completed wells are subject to conditions of 10 CSR 50-2.040(5))
Individual well permit
Blanket well permit
PERMIT INTENT (SELECT ONE)
New well construction
Deepen well
Plug-back well
Recomplete well
Change use of well
Other (explain in comments box below)
WELL INFORMATION
PROPOSED WELL USE (SELECT ONE)
Production Well:
Oil
Commercial gas
Non-commercial gas
Coalbed methane
Injection Well:
Enhanced oil recovery
Disposal of formation fluids
Cyclic steam stimulation
Other (explain in comments box below)
Other Well Usage:
Stratigraphic test
Observation for __________________________________________
Other (explain in comments box below)
WELL ORIENTATION (SELECT ONE)
NUMBER OF ABANDONED
(UNPLUGGED) WELLS ON LEASE
Vertical Well
Proposed depth
_____________ FT.
Plug back depth
____________ FT.
Horizontal Well
Measured vertical depth
_____________ FT.
Horizontal borehole length ____________ FT.
PRODUCTION UNIT (LEASE OR SURFACE UNIT
GEOLOGIC STRATUM NAME (USE MISSOURI
WELL NUMBER
GROUND ELEVATION
API NUMBER (FOR EXISTING
WELL ONLY)
NOMENCLATURE)
NAME)
FT.
BOND INFORMATION
Single well bond
Blanket well bond
On file
Attached
BOND TYPE
BOND STATUS
PROPOSED NEW WELL CONSTRUCTION AND CASING/TUBING SPECIFICATIONS
PLANNED SPUD DATE
PROPOSED DRILLING METHOD
COMMENTS
Coring
Rotary
Casing/Tubing Type
Setting Depth Diameter
Weight/Foot Packer Depth Full Length Cement (If no, explain alternative proposed method)
Yes
No
Yes
No
Yes
No
Yes
No
REQUIRED INFORMATION FOR SUBMISSION
If this permit is approved, you agree to submit all well information obtained including: driller’s log, e-log(s), core analyses, drill stem test, and additional requirements as
indicated below. For new well permit applications, the well location information must be submitted on the back of this form.
METHOD OF PAYMENT
Check or Money Order (Please enclose check, payable to Department of Natural Resources, with submitted form.)
AMOUNT DUE
Credit Card (Transaction fee applies.) (Please attach contact information of person authorized to make transaction.)
$100
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 an agent for the applicant of this well.
 The information on this application has been reviewed by me and is true, correct and complete to the best of my knowledge.
 I understand this permit, if approved, is not transferable to another party or location.
 I understand the submittal fee assessed to this well is non-refundable and non-transferable.
 I understand the submission of this application does not guarantee its approval.
 I understand this application will become null and void if no response has been received after thirty (30) days of notification requesting required missing or incomplete
information, at which time, the applicant may opt to submit a new application and associated fee for review.
 I understand additional requirements, as indicated below, may be a condition for the approval of this permit.
 I understand this permit, if for a single well, is valid for one (1) year after date of approval.
 I agree to abide by Chapter 259, RSMo, and the Missouri Code of State Regulations Oil and Gas Council Rules 10 CSR 50.
 I understand this permit, in no way, relieves me of my obligations to comply with all applicable federal, state and local laws or regulations.
NAME (PRINT)
TITLE
COMPANY
PRIMARY PHONE NUMBER WITH AREA CODE
EMAIL ADDRESS
SIGNATURE
DATE
FOR OFFICE USE ONLY
ADDITIONAL REQUIREMENTS
None
Cuttings on five foot interval
Core
Water sample(s) depth: ______________________________
Other _______________________________
APPROVED BY
APPROVAL DATE
PERMIT EXPIRATION DATE
MO 780-0211 (3-18)
SEND COMPLETED FORM ALONG WITH $100 APPLICATION FEE TO: MISSOURI DEPARTMENT OF NATURAL RESOURCES, MISSOURI GEOLOGICAL SURVEY,
oilandgas@dnr.mo.gov
GEOLOGIC RESOURCES SECTION, PO BOX 250, ROLLA, MO 65402 PHONE: 573-368-2100 FAX: 573-368-2111 EMAIL:
FOR NEW WELL PERMIT APPLICATIONS, THE WELL LOCATION INFORMATION MUST BE SUBMITTED ON THIS FORM.
(LATITUDE AND LONGITUDE MUST BE NAD83 AND AS DECIMAL DEGREE TO THE FIFTH DECIMAL)
COUNTY
LEGAL DESCRIPTION
LATITUDE
LONGITUDE
Sec.
Twp.
N Rng.
E
W
GRID INSTRUCTIONS Use this grid, or an approved map attachment, to clearly and precisely illustrate (draw, plot, etc.) the following:
Blanket permits must be accompanied by a plat of the entire production unit with information outlined in 10 CSR 50-2.030(5)
Location of the proposed well relative to the section lines
Location of the spacing or production unit lines relative to the section lines
Location of the nearest existing well that injects into, produces from or is open to the same reservoir as the proposed well
Distance from the proposed well to the nearest well as described above
Distance from the proposed well to the nearest spacing or production unit line
Distance from the proposed well to the two nearest section lines
In addition, for horizontal wells, mark the proposed wellhead location and borehole’s horizontal path to its terminus. Provide the
information above for the wellhead location and terminus of the horizontal borehole.
GRID AND SCALE EXPLANATION:
This grid represents the section of land
noted in the legal description at the top
of this page. The section is oriented as
per the north arrow shown immediately
above and is a one square mile
section of land divided into 64 square
cells. The side of each cell measures
660 feet in length; therefore, one-
fourth of each cell side equals 165
feet.
LAND OWNER INFORMATION ON WHICH THE WELL IS LOCATED (PER 10 CSR 50-2.030(3)(A)(4))
NAME (PRINT)
EMAIL ADDRESS
MAILING ADDRESS
CITY
STATE
ZIP
PHYSICAL ADDRESS (IF DIFFERENT THAN ABOVE)
PRIMARY PHONE NUMER WITH AREA CODE
COMMENTS
MO 780-0211 (3-18)
SEND COMPLETED FORM ALONG WITH $100 APPLICATION FEE TO: MISSOURI DEPARTMENT OF NATURAL RESOURCES, MISSOURI GEOLOGICAL SURVEY,
oilandgas@dnr.mo.gov
GEOLOGIC RESOURCES SECTION, PO BOX 250, ROLLA, MO 65402 PHONE: 573-368-2100 FAX: 573-368-2111 EMAIL:
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