Form 8000-FM-OOGM0138U "Oil and Gas Operations Well Development Impoundment Registration (Unconventional Operations Only)" - Pennsylvania

What Is Form 8000-FM-OOGM0138U?

This is a legal form that was released by the Pennsylvania Department of Environmental Protection - a government authority operating within Pennsylvania. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on March 1, 2017;
  • The latest edition provided by the Pennsylvania Department of Environmental Protection;
  • 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 printable version of Form 8000-FM-OOGM0138U by clicking the link below or browse more documents and templates provided by the Pennsylvania Department of Environmental Protection.

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Download Form 8000-FM-OOGM0138U "Oil and Gas Operations Well Development Impoundment Registration (Unconventional Operations Only)" - Pennsylvania

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8000-FM-OOGM0138U
Rev. 3/2017
COMMONWEALTH OF PENNSYLVANIA
DEP USE
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Site No.
OFFICE OF OIL AND GAS MANAGEMENT
Client No.
OIL AND GAS OPERATIONS WELL
DEVELOPMENT IMPOUNDMENT
APS No.
REGISTRATION
(Unconventional Operations Only)
A.
OPERATOR IDENTIFICATION
Well Operator
DEP ID / OGO No.
Address
City
State
Zip Code
  
Telephone No.
Fax No.
Email
B.
WELL DEVELOPMENT IMPOUNDMENT IDENTIFICATION
ESCGP No. (if any)
Impoundment Name
Date Constructed
County (Well)
Municipality (Well)
Latitude (DD)
Longitude (DD)
  .    
-  .    
C.
CERTIFICATION OF EXISTING AND NEWLY CONSTRUCTED IMPOUNDMENTS
(check all boxes that apply)
An individual will be continuously present at the well development impoundment OR a fence completely surrounds the well
development impoundment
The well development impoundment has been constructed with a synthetic impervious liner
Mine influenced water will be stored in the impoundment in accordance with a mine influenced water storage plan approved
by DEP
D.
SEASONAL HIGH GROUNDWATER DETERMINATION (NEWLY CONSTRUCTED IMPOUNDMENTS ONLY)
The bottom of the well development impoundment is at least 20 inches above the seasonal high groundwater table
If the impoundment will be less than the required separation distance of 20 inches a passive artificial means will be installed and
maintained
Name of the individual certifying that the bottom is at least 20 inches above the seasonal high groundwater table
Qualifications
Basis of Determination
E.
STRUCTURAL INTEGRITY ENGINEER CERTIFICATION (NEWLY CONSTRUCTED IMPOUNDMENTS ONLY)
Dam embankments for this impoundment have been designed and constructed in accordance with section 78a.59a.
Dam embankments for this impoundment have been designed and constructed in accordance with an alternative standard to the
specification outlined in section 78a.59a. If this box is checked, please include a demonstration that the alternative standard
provides equivalent or superior protection to the requirements of section 78a.59a
- 1 -
8000-FM-OOGM0138U
Rev. 3/2017
COMMONWEALTH OF PENNSYLVANIA
DEP USE
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Site No.
OFFICE OF OIL AND GAS MANAGEMENT
Client No.
OIL AND GAS OPERATIONS WELL
DEVELOPMENT IMPOUNDMENT
APS No.
REGISTRATION
(Unconventional Operations Only)
A.
OPERATOR IDENTIFICATION
Well Operator
DEP ID / OGO No.
Address
City
State
Zip Code
  
Telephone No.
Fax No.
Email
B.
WELL DEVELOPMENT IMPOUNDMENT IDENTIFICATION
ESCGP No. (if any)
Impoundment Name
Date Constructed
County (Well)
Municipality (Well)
Latitude (DD)
Longitude (DD)
  .    
-  .    
C.
CERTIFICATION OF EXISTING AND NEWLY CONSTRUCTED IMPOUNDMENTS
(check all boxes that apply)
An individual will be continuously present at the well development impoundment OR a fence completely surrounds the well
development impoundment
The well development impoundment has been constructed with a synthetic impervious liner
Mine influenced water will be stored in the impoundment in accordance with a mine influenced water storage plan approved
by DEP
D.
SEASONAL HIGH GROUNDWATER DETERMINATION (NEWLY CONSTRUCTED IMPOUNDMENTS ONLY)
The bottom of the well development impoundment is at least 20 inches above the seasonal high groundwater table
If the impoundment will be less than the required separation distance of 20 inches a passive artificial means will be installed and
maintained
Name of the individual certifying that the bottom is at least 20 inches above the seasonal high groundwater table
Qualifications
Basis of Determination
E.
STRUCTURAL INTEGRITY ENGINEER CERTIFICATION (NEWLY CONSTRUCTED IMPOUNDMENTS ONLY)
Dam embankments for this impoundment have been designed and constructed in accordance with section 78a.59a.
Dam embankments for this impoundment have been designed and constructed in accordance with an alternative standard to the
specification outlined in section 78a.59a. If this box is checked, please include a demonstration that the alternative standard
provides equivalent or superior protection to the requirements of section 78a.59a
- 1 -
8000-FM-OOGM0138U
Rev. 3/2017
I
, do hereby certify pursuant to the penalties of 18 Pa.C.S.A. Section 4904 to the best of
my knowledge, information, and belief that the well development impoundment subjected to this registration has been designed in
accordance with accepted engineering practices, is true and correct, and is in conformance with Chapter 78a of the rules and
regulation of the Department of Environmental Protection.
ENGINEER’S SEAL
PE
(Print Name)
(Date)
PE
(Signature)
F.
APPLICANT CERTIFICATION AND SIGNATURE
I certify under penalty of law that I have personally examined and I am familiar with the information submitted in this and that based on
my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true,
accurate and complete.
BY
(Print Name)
(Signature)
(Date)
(Title)
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