Form 5500-PM-OG0008 "Application for an Order to Clean out and Plug or Replug a Non-producing Gas Well Under Section 12(C) of Act 214" - Pennsylvania

What Is Form 5500-PM-OG0008?

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

Form Details:

  • Released on November 1, 2008;
  • 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 5500-PM-OG0008 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 5500-PM-OG0008 "Application for an Order to Clean out and Plug or Replug a Non-producing Gas Well Under Section 12(C) of Act 214" - Pennsylvania

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DEP USE
Auth #
ONLY
APS #
5500-PM-OG0008
Rev. 11/2008
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Site #
Facility #
BUREAU OF OIL AND GAS MANAGEMENT
Client #
Sub-facility #
APPLICATION FOR AN ORDER TO CLEAN OUT AND PLUG OR REPLUG
A NON-PRODUCING GAS WELL UNDER SECTION 13(C) of ACT 214
Please read instructions on reverse before completing this form
SECTION A. APPLICANT INFORMATION
SECTION B. OTHER AFFECTED PARTIES
SURFACE OWNER
Name
Name
Address
Address
City
State
Zip
Address
Telephone
Fax
Telephone
Fax
GAS WELL INFORMATION
OIL AND GAS LESSOR
Farm Name
Name
Well No.
Serial No.
Address
Municipality (City, Borough, or Township)
Address
County
Phone
Fax
OIL AND GAS LESSEE
Well Permit/Reg. No., if known
Date Drilled, if known
Name
Is this well the object of a Coal Pillar Permit?
Yes
No
Address
Number
SECTION C. ADDITIONAL INFORMATION REQUIRED
Address
Telephone
Fax
Checklist
Well Location Plat: Form 5500-FM-OG0002
SECTION D. SIGNATURE BLOCK
Copy of or record reference to a deed, lease
I HEREBY CERTIFY THAT I HAVE SENT BY Certified or
or other document entitling the applicant to
Registered Mail a copy of this application to the surface
enter upon the surface land
landowner, the oil and gas lessor and lessee as identified
above, and the coal owners and operators of all mineable
Proposed method of cleaning out, plugging
coal seams.
or replugging the well
Notice of Intention to Plug (5500-FM-OG0005)
(If previously submitted check this box)
Signature of Applicant
If alternative method of plugging is proposed,
Yes
is Form 5500-PM-OG0024 attached?
No
Type or Print Name and Title
Date
DEP USE
Auth #
ONLY
APS #
5500-PM-OG0008
Rev. 11/2008
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Site #
Facility #
BUREAU OF OIL AND GAS MANAGEMENT
Client #
Sub-facility #
APPLICATION FOR AN ORDER TO CLEAN OUT AND PLUG OR REPLUG
A NON-PRODUCING GAS WELL UNDER SECTION 13(C) of ACT 214
Please read instructions on reverse before completing this form
SECTION A. APPLICANT INFORMATION
SECTION B. OTHER AFFECTED PARTIES
SURFACE OWNER
Name
Name
Address
Address
City
State
Zip
Address
Telephone
Fax
Telephone
Fax
GAS WELL INFORMATION
OIL AND GAS LESSOR
Farm Name
Name
Well No.
Serial No.
Address
Municipality (City, Borough, or Township)
Address
County
Phone
Fax
OIL AND GAS LESSEE
Well Permit/Reg. No., if known
Date Drilled, if known
Name
Is this well the object of a Coal Pillar Permit?
Yes
No
Address
Number
SECTION C. ADDITIONAL INFORMATION REQUIRED
Address
Telephone
Fax
Checklist
Well Location Plat: Form 5500-FM-OG0002
SECTION D. SIGNATURE BLOCK
Copy of or record reference to a deed, lease
I HEREBY CERTIFY THAT I HAVE SENT BY Certified or
or other document entitling the applicant to
Registered Mail a copy of this application to the surface
enter upon the surface land
landowner, the oil and gas lessor and lessee as identified
above, and the coal owners and operators of all mineable
Proposed method of cleaning out, plugging
coal seams.
or replugging the well
Notice of Intention to Plug (5500-FM-OG0005)
(If previously submitted check this box)
Signature of Applicant
If alternative method of plugging is proposed,
Yes
is Form 5500-PM-OG0024 attached?
No
Type or Print Name and Title
Date
5500-PM-OG0008
Rev. 11/2008
Instructions
Use this form to apply for an “Order to Clean Out and Plug
or Replug a Non-Producing Gas Well Under Section 13(c) of
Act 214.” This applies only to an abandoned well which
penetrates a workable coal seam.
SECTION A. APPLICANT INFORMATION
Enter
the
name
of
the
person,
corporation,
or
unincorporated
business
which
is
requesting
the
Department order to plug or replug the well.
If the well is the object of a coal pillar permit, please identify
the pillar by number.
GAS WELL INFORMATION:
Provide information that
identifies and locates the gas well, not the location of the
mine portal nor the well operator’s address.
SECTION B. OTHER AFFECTED PARTIES
If known, identify all other affected parties listed. Use an
additional 8½” x 11” sheet if necessary. If you don’t know
who they are, print “unknown”.
SECTION C. ADDITIONAL FORMS REQUIRED
Use this checklist to see that this application is completed.
If the well is to be cleaned out, plugged or replugged by a
method, or using materials other than described in Act 214,
subsections 13(a)(1) or (2), then a request for approval to
use an alternate method or materials must be filed. You
must submit a plan for a Proposed Alternate Method of
Casing, Plugging, Venting or Equipping on Form 5500-PM-
OG0024.
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