Form 8000-PM-OOGM0110 "Permit Application to Adopt an Oil or Gas Well" - Pennsylvania

What Is Form 8000-PM-OOGM0110?

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 November 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-PM-OOGM0110 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-PM-OOGM0110 "Permit Application to Adopt an Oil or Gas Well" - Pennsylvania

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8000-PM-OOGM0110
Rev. 11/2017
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OFFICE OF OIL AND GAS MANAGEMENT
PERMIT APPLICATION TO ADOPT AN OIL OR GAS WELL
A. APPLICANT INFORMATION
Applicant Name
Applicant Notification
Pursuant to the notification requirements of Section 3211(b.2) of 58
Address
DEP ID / OGO No.
Pa. C.S. Sections 3201-3274 (“2012 Oil and Gas Act”), the applicant
is hereby notified of both statutory and regulatory obligations to
City
State
Zip Code
Project No. (If previously assigned by DEP)
properly plug any adopted well upon abandonment.
  
Telephone No.
Fax No.
B. WELL INFORMATION
Group wells by county and use a separate form to list wells in each different county.
Was Well Involved
in Hydraulic
Fracturing
Communication
Incident/Evidence
US Well No.
Well (Farm)
Serial
Date
Total
of Integrity
Latitude
Longitude
(API No.)
County
Municipality
Name
Well No.
No.
Drilled Well Type
Depth
Quad
Section
Failure?
(DD)
(DD)
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
Attachments Checklist (please check all that apply)
Applicant Signature
1.
Well Locations Plotted on a USGS 7.5 Minute Topographic Map
Subject to the penalties of Title 18-Pa C.S. Section 4904 relating to unsworn falsification to authorities, I certify
that I have the authority to submit this request to operate the above-listed abandoned wells. Further, I certify that
2.
Driller’s Log, if available
the information provided on this form and attachments is true and correct to the best of my knowledge and
information.
3.
Any Additional Well Information Available
Signature
Date
4.
Workover Summary, if required
5.
Operating/Ownership Interests Information
Type or Print Name and Title
8000-PM-OOGM0110
Rev. 11/2017
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OFFICE OF OIL AND GAS MANAGEMENT
PERMIT APPLICATION TO ADOPT AN OIL OR GAS WELL
A. APPLICANT INFORMATION
Applicant Name
Applicant Notification
Pursuant to the notification requirements of Section 3211(b.2) of 58
Address
DEP ID / OGO No.
Pa. C.S. Sections 3201-3274 (“2012 Oil and Gas Act”), the applicant
is hereby notified of both statutory and regulatory obligations to
City
State
Zip Code
Project No. (If previously assigned by DEP)
properly plug any adopted well upon abandonment.
  
Telephone No.
Fax No.
B. WELL INFORMATION
Group wells by county and use a separate form to list wells in each different county.
Was Well Involved
in Hydraulic
Fracturing
Communication
Incident/Evidence
US Well No.
Well (Farm)
Serial
Date
Total
of Integrity
Latitude
Longitude
(API No.)
County
Municipality
Name
Well No.
No.
Drilled Well Type
Depth
Quad
Section
Failure?
(DD)
(DD)
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
Attachments Checklist (please check all that apply)
Applicant Signature
1.
Well Locations Plotted on a USGS 7.5 Minute Topographic Map
Subject to the penalties of Title 18-Pa C.S. Section 4904 relating to unsworn falsification to authorities, I certify
that I have the authority to submit this request to operate the above-listed abandoned wells. Further, I certify that
2.
Driller’s Log, if available
the information provided on this form and attachments is true and correct to the best of my knowledge and
information.
3.
Any Additional Well Information Available
Signature
Date
4.
Workover Summary, if required
5.
Operating/Ownership Interests Information
Type or Print Name and Title