Form 85-12-4-27B "Notice of Intention to Plug and Abandon" - New York

What Is Form 85-12-4-27B?

This is a legal form that was released by the New York State Department of Environmental Conservation - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2018;
  • The latest edition provided by the New York State Department of Environmental Conservation;
  • 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 85-12-4-27B by clicking the link below or browse more documents and templates provided by the New York State Department of Environmental Conservation.

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Download Form 85-12-4-27B "Notice of Intention to Plug and Abandon" - New York

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DIVISION OF MINERAL RESOURCES
NOTICE OF INTENTION TO PLUG AND ABANDON
THIS NOTICE IS A LEGAL DOCUMENT. READ THE APPLICABLE AFFIRMATION AND SIGNATURE CAREFULLY BEFORE SIGNING.
PRINT OR TYPE IN BLACK INK For Instructions on completing this form, visit the Division's website at
www.dec.ny.gov/energy/205.html
or contact your local Regional office.
WELL OWNER (Full name of Organization or Individual as registered with the Division)
API WELL IDENTIFICATION NUMBER
31
-
-
-
-
ADDRESS (P.O. Box or Street Address, City State, Zip Code)
WELL NAME AND NUMBER
COUNTY
TOWN
7 ½ MINUTE QUAD NAME
QUAD SECTION
TOTAL DEPTH
PLUG BACK DEPTH
LOCATION DESCRIPTION
DECIMAL LATITUDE (NAD83)
DECIMAL LONGITUDE (NAD83)
Surface
0’
0’
____ ____ . ____ ____ ____ ____ ____ ____
____ ____ . ____ ____ ____ ____ ____ ____
Top of Target Interval
____ ____ . ____ ____ ____ ____ ____ ____
____ ____ . ____ ____ ____ ____ ____ ____
Bottom of Target Interval
____ ____ . ____ ____ ____ ____ ____ ____
____ ____ . ____ ____ ____ ____ ____ ____
Bottom Hole
____ ____ . ____ ____ ____ ____ ____ ____
____ ____ . ____ ____ ____ ____ ____ ____
TVD
TMD
For vertical wells, use TMD to record depths
PLANNED DATE AND TIME OF COMMENCEMENT OF OPERATIONS
NAME OF PLANNED PLUGGING CONTRACTOR (as registered with the Department)
TELEPHONE NUMBER (include area code)
PUT IN WELL
PULLED OUT
LEFT IN WELL
METHOD
CASING STRINGS
HOLE SIZE (in.)
PIPE SIZE (in.)
WEIGHT (lbs./ft.)
NEW OR USED
(TMD)
(TMD)
(TMD)
(cut, shot, etc.)
Drive Pipe or Conductor
Surface or Water
Intermediate
Production
Liners
Enter proposed plugging plan starting from total depth
FILLING MATERIALS
CLASS/TYPE OF CEMENT OR
NUMBER OF
SLURRY
YIELD
VOLUME
TAGGED
FROM
TO
BRIDGES AND PLUGS
OTHER MATERIAL
SACKS
WT (ppg)
(ft.
3
/sx)
(ft.
3
)
(YES/NO)
(TVD/TMD)
(TVD/TMD)
DEPARTMENT USE ONLY
BOND NUMBER
PLUGGING PERMIT NUMBER
DATE ISSUED
PAGE 1 OF 2
85-12-4–27b (12/18)
PRINT
DIVISION OF MINERAL RESOURCES
NOTICE OF INTENTION TO PLUG AND ABANDON
THIS NOTICE IS A LEGAL DOCUMENT. READ THE APPLICABLE AFFIRMATION AND SIGNATURE CAREFULLY BEFORE SIGNING.
PRINT OR TYPE IN BLACK INK For Instructions on completing this form, visit the Division's website at
www.dec.ny.gov/energy/205.html
or contact your local Regional office.
WELL OWNER (Full name of Organization or Individual as registered with the Division)
API WELL IDENTIFICATION NUMBER
31
-
-
-
-
ADDRESS (P.O. Box or Street Address, City State, Zip Code)
WELL NAME AND NUMBER
COUNTY
TOWN
7 ½ MINUTE QUAD NAME
QUAD SECTION
TOTAL DEPTH
PLUG BACK DEPTH
LOCATION DESCRIPTION
DECIMAL LATITUDE (NAD83)
DECIMAL LONGITUDE (NAD83)
Surface
0’
0’
____ ____ . ____ ____ ____ ____ ____ ____
____ ____ . ____ ____ ____ ____ ____ ____
Top of Target Interval
____ ____ . ____ ____ ____ ____ ____ ____
____ ____ . ____ ____ ____ ____ ____ ____
Bottom of Target Interval
____ ____ . ____ ____ ____ ____ ____ ____
____ ____ . ____ ____ ____ ____ ____ ____
Bottom Hole
____ ____ . ____ ____ ____ ____ ____ ____
____ ____ . ____ ____ ____ ____ ____ ____
TVD
TMD
For vertical wells, use TMD to record depths
PLANNED DATE AND TIME OF COMMENCEMENT OF OPERATIONS
NAME OF PLANNED PLUGGING CONTRACTOR (as registered with the Department)
TELEPHONE NUMBER (include area code)
PUT IN WELL
PULLED OUT
LEFT IN WELL
METHOD
CASING STRINGS
HOLE SIZE (in.)
PIPE SIZE (in.)
WEIGHT (lbs./ft.)
NEW OR USED
(TMD)
(TMD)
(TMD)
(cut, shot, etc.)
Drive Pipe or Conductor
Surface or Water
Intermediate
Production
Liners
Enter proposed plugging plan starting from total depth
FILLING MATERIALS
CLASS/TYPE OF CEMENT OR
NUMBER OF
SLURRY
YIELD
VOLUME
TAGGED
FROM
TO
BRIDGES AND PLUGS
OTHER MATERIAL
SACKS
WT (ppg)
(ft.
3
/sx)
(ft.
3
)
(YES/NO)
(TVD/TMD)
(TVD/TMD)
DEPARTMENT USE ONLY
BOND NUMBER
PLUGGING PERMIT NUMBER
DATE ISSUED
PAGE 1 OF 2
85-12-4–27b (12/18)
API WELL IDENTIFICATION NUMBER
WELL OWNER (Full name of Organization or Individual as registered with the Division)
31
-
-
-
-
GIVE DETAILS FOR EACH OF THE PROPOSED CEMENT PLUGS INCLUDING BUT NOT LIMITED TO: how the cement will be mixed (by hand, mechanical mixer, service
company, etc.), how the plug will be placed in the well (through pipe on gel, through pipe on a bridge, bullhead, squeeze, etc.) size of the tubing, casing or drill pipe used to place
the plug in the well, and how the cement will be put into the well (pumped or gravity feed).
FOR DIRECTIONAL OR SIDETRACK WELLS also include a well bore diagram showing the location of each of the plugs noted in the above referenced details.
FOR WELLS NOT CURRENTLY REGISTERED WITH THE DEPARTMENT list the well type and also submit a map showing the location of the well.
WELL FLARING DURING PLUGGING
Will any flaring be required during the proposed plugging operation?
Yes
No
Unknown at this time
If “Yes," the applicant must complete and attach an Application for Approval to Flare form available at http://www.dec.ny.gov/energy/4761.html. Application to the Department
for a flare approval or extension of a previously approved flaring period shall be made on such form. If “Unknown at this time,” the applicant must complete and submit an
Application for Approval to Flare at a later date, and obtain Department approval prior to any flaring.
AFFIRMATION AND SIGNATURE
A.
For use by individual:
I affirm under penalty of perjury that the information provided in this form is true to the best of my knowledge and belief. I am
aware any false statement made in this form is punishable pursuant to Section 210.45 of the Penal Law.
________________________________________________________
Printed or Typed Name of Individual
________________________________________________________
________________________
Signature of Individual
Date
B.
For use by organizations other than an individual:
I affirm under penalty of perjury that I am ______________________________________________________________ (title)
of ___________________________________________________________________ (organization); that I am authorized by
the organization to complete this form; that this form was prepared under my supervision and direction; and that the
information provided in this form is true to the best of my knowledge and belief. I am aware ant false statement made in this
form is punishable pursuant to Section 210.45 of the Penal Law.
________________________________________________________
Printed or Typed Name of Authorized Representative
________________________________________________________
________________________
Signature of Authorized Representative
Date
PAGE 2 OF 2
85-12-4–27b (12/18)
Page of 2