Form MO780-0217 "Oil and Gas Well Plugging Report - Geological Survey Program" - Missouri

What Is Form MO780-0217?

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 MO780-0217 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 MO780-0217 "Oil and Gas Well Plugging Report - Geological Survey Program" - Missouri

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MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR OFFICE USE ONLY
DATE RECEIVED
GEOLOGICAL SURVEY PROGRAM
CHECK AMOUNT
CHECK NUMBER
OIL AND GAS WELL PLUGGING REPORT
PROCESSED BY
WELL OWNER INFORMATION
NAME OF COMPANY, ORGANIZATION, OR INDIVIDUAL THAT DRILLS, MAINTAINS, OPERATES, OR CONTROLS OIL AND GAS WELLS IN MISSOURI OPERATOR LICENSE NUMBER
MAILING ADDRESS
CITY
STATE
ZIP CODE
PRIMARY CONTACT NAME
TITLE
PRIMARY PHONE NUMBER WITH
EMAIL ADDRESS
AREA CODE
WELL INFORMATION (LATITUDE AND LONGITUDE MUST BE NAD83 AND AS DECIMAL DEGREE TO THE FIFTH DECIMAL)
COUNTY
LEGAL DESCRIPTION
LATITUDE
LONGITUTDE
Sec. _____
Twp. _____ N
Rng. _____
E
W
PRODUCTION UNIT (LEASE OR SURFACE UNIT NAME)
WELL NUMBER
WELL PERMIT NUMBER
API NUMBER (FOR EXISTING WELL ONLY) GROUND ELEVATION
FT.
APPLICATION TO DRILL THIS WELL WAS FILED IN NAME OF
HAS THIS WELL EVER PRODUCED OIL OR GAS
DRY HOLE
TOTAL WELL DEPTH
Yes
No
Yes
No
FT.
WELL USE (SELECT ONE)
Commercial gas
Non-commercial gas
Coalbed methane
Production Well:
Oil
Injection Well:
Enhanced oil recovery
Disposal of formation fluids
Cyclic steam stimulation
Other (explain in comments box)
Other Well Usage:
Stratigraphic test
Observation for ___________________________________
Other (explain in comments box)
WELL ORIENTATION (SELECT ONE)
STATIC WELLHEAD PRESSURE
Vertical Well
Well depth
________
.
FT
Horizontal Well
Measured vertical depth
________
.
Horizontal borehole length __________
.
FT
FT
PSI
WELL PLUGGING INFORMATION
PLUGGING METHOD
DATE PLUGGED
Tremie
Pressure grout
Other (prior approval required) _____________________________________
Lithologic Information
Name of each stratum/strata
Stratum/strata
Fluid content of each
Depth interval of
Size, kind and depth of plugs
containing oil or gas
open to well bore
stratum/strata
each
used, stating amount of
at time of plugging
stratum/strata
cement/gel/mud
Yes
No
Yes
No
Yes
No
Well Construction Information
Size Pipe Put in Well (FT.) Pulled Out (FT.) Left in Well (FT.) Give Depth and Method of Parting
Packers and Shoes
Casing (Shot, Ripped, etc.)
SELECT ONE
BRIDGE PLUG
Perforated casing
Open hole Perforated/open hole depth interval: from
to
No
Yes, depth _________
FT.
FT.
FT.
Was all equipment associated with the well removed from the site?
Yes
No
Was the surface casing cut three feet beneath the land surface?
Yes
No
Was the well site left, as nearly as practical, in the same condition as it existed before the well was plugged?
Yes
No
METHOD OF DISPOSAL OF MUD PIT CONTENTS
COMMENTS
MO 780-0217 (03-18)
SEND COMPLETED FORM ALONG WITH $50 PLUGGING FEE, NO LATER THAN THIRTY (30) DAYS AFTER WELL HAS BEEN PLUGGED, TO:
MISSOURI DEPARTMENT OF NATURAL RESOURCES, MISSOURI GEOLOGICAL SURVEY, GEOLOGIC RESOURCES SECTION,
PO BOX 250, ROLLA, MO 65402 PHONE: 573-368-2100 FAX: 573-368-2111 EMAIL:
oilandgas@dnr.mo.gov
MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR OFFICE USE ONLY
DATE RECEIVED
GEOLOGICAL SURVEY PROGRAM
CHECK AMOUNT
CHECK NUMBER
OIL AND GAS WELL PLUGGING REPORT
PROCESSED BY
WELL OWNER INFORMATION
NAME OF COMPANY, ORGANIZATION, OR INDIVIDUAL THAT DRILLS, MAINTAINS, OPERATES, OR CONTROLS OIL AND GAS WELLS IN MISSOURI OPERATOR LICENSE NUMBER
MAILING ADDRESS
CITY
STATE
ZIP CODE
PRIMARY CONTACT NAME
TITLE
PRIMARY PHONE NUMBER WITH
EMAIL ADDRESS
AREA CODE
WELL INFORMATION (LATITUDE AND LONGITUDE MUST BE NAD83 AND AS DECIMAL DEGREE TO THE FIFTH DECIMAL)
COUNTY
LEGAL DESCRIPTION
LATITUDE
LONGITUTDE
Sec. _____
Twp. _____ N
Rng. _____
E
W
PRODUCTION UNIT (LEASE OR SURFACE UNIT NAME)
WELL NUMBER
WELL PERMIT NUMBER
API NUMBER (FOR EXISTING WELL ONLY) GROUND ELEVATION
FT.
APPLICATION TO DRILL THIS WELL WAS FILED IN NAME OF
HAS THIS WELL EVER PRODUCED OIL OR GAS
DRY HOLE
TOTAL WELL DEPTH
Yes
No
Yes
No
FT.
WELL USE (SELECT ONE)
Commercial gas
Non-commercial gas
Coalbed methane
Production Well:
Oil
Injection Well:
Enhanced oil recovery
Disposal of formation fluids
Cyclic steam stimulation
Other (explain in comments box)
Other Well Usage:
Stratigraphic test
Observation for ___________________________________
Other (explain in comments box)
WELL ORIENTATION (SELECT ONE)
STATIC WELLHEAD PRESSURE
Vertical Well
Well depth
________
.
FT
Horizontal Well
Measured vertical depth
________
.
Horizontal borehole length __________
.
FT
FT
PSI
WELL PLUGGING INFORMATION
PLUGGING METHOD
DATE PLUGGED
Tremie
Pressure grout
Other (prior approval required) _____________________________________
Lithologic Information
Name of each stratum/strata
Stratum/strata
Fluid content of each
Depth interval of
Size, kind and depth of plugs
containing oil or gas
open to well bore
stratum/strata
each
used, stating amount of
at time of plugging
stratum/strata
cement/gel/mud
Yes
No
Yes
No
Yes
No
Well Construction Information
Size Pipe Put in Well (FT.) Pulled Out (FT.) Left in Well (FT.) Give Depth and Method of Parting
Packers and Shoes
Casing (Shot, Ripped, etc.)
SELECT ONE
BRIDGE PLUG
Perforated casing
Open hole Perforated/open hole depth interval: from
to
No
Yes, depth _________
FT.
FT.
FT.
Was all equipment associated with the well removed from the site?
Yes
No
Was the surface casing cut three feet beneath the land surface?
Yes
No
Was the well site left, as nearly as practical, in the same condition as it existed before the well was plugged?
Yes
No
METHOD OF DISPOSAL OF MUD PIT CONTENTS
COMMENTS
MO 780-0217 (03-18)
SEND COMPLETED FORM ALONG WITH $50 PLUGGING FEE, NO LATER THAN THIRTY (30) DAYS AFTER WELL HAS BEEN PLUGGED, TO:
MISSOURI DEPARTMENT OF NATURAL RESOURCES, MISSOURI GEOLOGICAL SURVEY, GEOLOGIC RESOURCES SECTION,
PO BOX 250, ROLLA, MO 65402 PHONE: 573-368-2100 FAX: 573-368-2111 EMAIL:
oilandgas@dnr.mo.gov
DETAIL OF GEOLOGIC STRATUM/STRATA PENETRATED (ATTACH DRILLERS LOG OR OTHER ACCEPTABLE LOG OF
WELL IF AVAILABLE)
STRATA/STRATUM
Top
Bottom
Description (See * below)
*NOTE: Show all important zones of porosity, detail of all cores, and all drill-stem tests, indicating depth interval tested. Indicate zones
of fresh water penetrated.
WELL PLUGGING CONTRACTOR INFORMATION
NAME OF COMPANY, ORGANIZATION OR INDIVIDUAL
EMAIL ADDRESS
MAILING ADDRESS
CITY
STATE
ZIP CODE
COMPANY ONSITE REPRESENTATIVE
PRIMARY PHONE NUMBER WITH AREA CODE
METHOD OF PAYMENT
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.)
$50
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 owner of this well.
The information on this report has been reviewed by me and is true, correct and complete to the best of my knowledge.
I understand the submittal fee assessed to this well is non-refundable and non-transferable.
I understand that the submission of this report is not a guarantee of acceptance.
The plugging is in accordance with the Missouri Code of State Regulations Oil and Gas Rules 10 CSR 50.
PRINT NAME
SELECT ONE
COMPANY
Well owner
Well plugging contractor
PRIMARY TELEPHONE WITH AREA CODE
EMAIL ADDRESS
SIGNATURE
DATE
FOR OFFICE USE ONLY
The information submitted on this report indicates the plugging of this well.
Conforms with 10 CSR 50-2.060
Does not conform with 10 CSR 50-2.060
REVIEWED BY
DATE
MO 780-0217 (03-18)
SEND COMPLETED FORM ALONG WITH $50 PLUGGING FEE, NO LATER THAN THIRTY (30) DAYS AFTER WELL HAS BEEN PLUGGED, TO:
MISSOURI DEPARTMENT OF NATURAL RESOURCES, MISSOURI GEOLOGICAL SURVEY, GEOLOGIC RESOURCES SECTION,
PO BOX 250, ROLLA, MO 65402 PHONE: 573-368-2100 FAX: 573-368-2111 EMAIL:
oilandgas@dnr.mo.gov
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