Form 139 "Application for Permit to Drill or Reenter"

What Is Form 139?

This is a legal form that was released by the U.S. Department of the Interior - Indian Affairs, Osage Agency on March 1, 2015 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2015;
  • The latest available edition released by the U.S. Department of the Interior - Indian Affairs, Osage Agency;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 139 by clicking the link below or browse more documents and templates provided by the U.S. Department of the Interior - Indian Affairs, Osage Agency.

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Form 139 (Rev)
FORM APPROVED
(March 2015)
OMB No. [1076-0180]
Expires 3/31/2023
UNITED STATES
5. Lease Serial No.
DEPARTMENT OF THE INTERIOR
OSAGE AGENCY
6. If Indian, Allotee or Tribe Name
APPLICATION FOR PERMIT TO DRILL OR REENTER
1a. Type of work:
DRILL
REENTER
7. If Unit or CA Agreement, Name and No.
8. Lease Name and Well No.
1b. Type of Well:
Oil Well
Gas Well
Other
Single Zone
Multiple Zone
2. Name of Operator
9. API Well No.
3a. Address
3b. Phone No. (include area code)
10. Field and Pool, or Exploratory
4. Location of Well (Report location clearly*)
11. Sec., T.R.M. or Blk. And Survey or Area
At surface
At proposed prod. zone
14. Distance in miles and direction from nearest town or post office*
12. Country or
13. State
Parish
15. Distance from proposed*
16. No. of acres in lease
17. Spacing Unit dedicated to this well
location to nearest
property or lease line, ft.
(Also to nearest drig. unit line, if any)
18. Distance from proposed location*
19. Proposed Depth
20. BIA Bond No. on file
to nearest well, drilling, completed,
applied for, on this lease, ft.
21. Elevations (Show whether DF, KDB, RT, GL, etc.)
22. Approximate date work will start*
23. Estimated
duration
24. Attachments
The following, completed in accordance with 25 C.F.R. Part 226, must be attached to this form:
1. Well plate certified by registered surveyor
3. Bond to cover the operations unless covered by an existing bond on file (see
2. A Drilling Plan.
Item 20 above).
4. Operator certification
5. Such other site specific information and/or plans as may be required by the
BIA.
25. Signature
Name (Printed/Typed)
Date
Title
Approved by (Signature)
Name (Printed/Typed)
Date
Title
Office
Application approval does not warrant or certify that the applicant holds legal or equitable title to those rights in the subject lease which would entitle the applicant
to conduction operations thereon.
Conditions of approval, if any, are attached.
Title 18 U.S.C., Section 1001 and Title 43 U.S.C., Section 1212, make it a crime for any person knowingly and willfully to make to any department or agency of the
United States any false, fictitious or fraudulent statements or representations as to any matter within its jurisdiction.
(Continued on page 2)
*(Instructions on page 2)
Form 139 (Rev)
FORM APPROVED
(March 2015)
OMB No. [1076-0180]
Expires 3/31/2023
UNITED STATES
5. Lease Serial No.
DEPARTMENT OF THE INTERIOR
OSAGE AGENCY
6. If Indian, Allotee or Tribe Name
APPLICATION FOR PERMIT TO DRILL OR REENTER
1a. Type of work:
DRILL
REENTER
7. If Unit or CA Agreement, Name and No.
8. Lease Name and Well No.
1b. Type of Well:
Oil Well
Gas Well
Other
Single Zone
Multiple Zone
2. Name of Operator
9. API Well No.
3a. Address
3b. Phone No. (include area code)
10. Field and Pool, or Exploratory
4. Location of Well (Report location clearly*)
11. Sec., T.R.M. or Blk. And Survey or Area
At surface
At proposed prod. zone
14. Distance in miles and direction from nearest town or post office*
12. Country or
13. State
Parish
15. Distance from proposed*
16. No. of acres in lease
17. Spacing Unit dedicated to this well
location to nearest
property or lease line, ft.
(Also to nearest drig. unit line, if any)
18. Distance from proposed location*
19. Proposed Depth
20. BIA Bond No. on file
to nearest well, drilling, completed,
applied for, on this lease, ft.
21. Elevations (Show whether DF, KDB, RT, GL, etc.)
22. Approximate date work will start*
23. Estimated
duration
24. Attachments
The following, completed in accordance with 25 C.F.R. Part 226, must be attached to this form:
1. Well plate certified by registered surveyor
3. Bond to cover the operations unless covered by an existing bond on file (see
2. A Drilling Plan.
Item 20 above).
4. Operator certification
5. Such other site specific information and/or plans as may be required by the
BIA.
25. Signature
Name (Printed/Typed)
Date
Title
Approved by (Signature)
Name (Printed/Typed)
Date
Title
Office
Application approval does not warrant or certify that the applicant holds legal or equitable title to those rights in the subject lease which would entitle the applicant
to conduction operations thereon.
Conditions of approval, if any, are attached.
Title 18 U.S.C., Section 1001 and Title 43 U.S.C., Section 1212, make it a crime for any person knowingly and willfully to make to any department or agency of the
United States any false, fictitious or fraudulent statements or representations as to any matter within its jurisdiction.
(Continued on page 2)
*(Instructions on page 2)
INSTRUCTIONS
GENERAL: This form is designed for submitting proposals to perform certain well operations, as indicated on Indian lands and leases
for action by appropriate Federal agencies, pursuant to applicable Federal laws and regulations.
ITEM 1: If the proposal is to redrill to the same reservoir at a different subsurface location or to a new reservoir, use this form with
appropriate notations. Consult applicable Federal regulations concerning subsequent work proposals or reports on the well.
ITEM 4: Locations on Indian land should be described in accordance with Federal requirements. Consult local Federal offices for
specific instructions.
ITEM 14: Needed only when location of well cannot readily be found by road from the land or lease description. A plat, or plats
separate or on the reverse side, showing the roads to, and the surveyed location of, the well, and any other required information, should
be furnished when required by Federal agency offices.
ITEM 15 AND 18: If well is to be, or has been directionally drilled, give distances for subsurface location of hold in any present or
objective productive zone.
ITEM 22: Consult applicable Federal regulations, or appropriate officials, concerning approval of the proposal before operations are
started.
NOTICES
The Privacy Act of 1974 and regulation in 25 C.F.R. 226.34(b) provide that you be furnished the following information in connection
with information required by this application.
AUTHORITY: 25 C.F.R. Part 226, 200 DM 1, 209 DM 8, 230 DM 1, 3 IAM 4.1 and Muscogee Area Addendum 9901 to 3 IAM 4
PRINCIPAL PURPOSES: The information will be used to (1) process and evaluate your application for a permit to drill a new oil,
gas, or service well or to reenter a plugged and abandoned well; and (2) document, for administrative use, information for the
management, disposal and use of National Resource Lands and resources including (a) analyzing your proposal to discover and extract
the Indian resources encountered; (b) reviewing procedures and equipment and the projected impact on the land involved; and (c)
evaluating the effects of the proposed operation on the surface and subsurface water and other environmental impacts.
ROUTINE USE: Information from the record and/or the record will be transferred to appropriate Federal, State, and local or foreign
agencies, when relevant to civil, criminal or regulatory investigations or prosecution, in connection with congressional inquiries and
for regulatory responsibilities.
EFFECT OF NOT PROVIDING INFORMATION: Filing of this application and disclosure of the information is mandatory only if
you elect to initiate a drilling or reentry operation on an oil and gas lease.
The Paperwork Reduction Act of 1995 requires us to inform you that:
The BIA/Osage Agency collects this information to allow evaluation of the technical, safety, and environmental factors involved with
drilling for oil and/or gas on Federal and Indian oil and gas leases. This information will be used to analyze and approve applications.
Response to this request is mandatory only if the operator elects to initiate drilling or reentry operations on an oil and gas lease. The
BIA/Osage Agency would like you to know that you do not have to respond to this or any other Federal agency-sponsored information
collection unless it displays a valid OMB Control Number.
BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average 8 hours per response, including the
time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding
the burden estimate or any other aspect of this form to: Information Collection Clearance Officer – Indian Affairs, 1849 C Street,
N.W., Mail Stop 3642, Washington, DC 20240.
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