Form BSEE-0123 "Application for Permit to Drill (Apd)"

What Is Form BSEE-0123?

This is a legal form that was released by the U.S. Department of the Interior - Bureau of Safety and Environmental Enforcement on June 1, 2020 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2020;
  • The latest available edition released by the U.S. Department of the Interior - Bureau of Safety and Environmental Enforcement;
  • 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 fillable version of Form BSEE-0123 by clicking the link below or browse more documents and templates provided by the U.S. Department of the Interior - Bureau of Safety and Environmental Enforcement.

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Download Form BSEE-0123 "Application for Permit to Drill (Apd)"

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U.S. Department of the Interior
OMB Control No. 1014-0025 OMB
Submit original plus THREE copies,
Bureau of Safety and Environmental
Approval Expires 06/30/2023
with ONE copy marked "Public Information."
Enforcement (BSEE)
Application for Permit to Drill (APD)
PROPOSAL TO DRILL
1.
2. BSEE OPERATOR NO.
3. OPERATOR NAME and ADDRESS
NEW WELL
SIDETRACK
DEEPEN
BYPASS
(Submitting office)
4. WELL NAME (CURRENT)
5. SIDETRACK NO. (CURRENT)
6. BYPASS NO. (CURRENT)
7. PROPOSED START DATE
8. PLAN CONTROL NO. (NEW WELL ONLY)
9. API WELL NO. (CURRENT SIDETRACK / BYPASS) (12 DIGITS)
If revision, list
10.
Revision
11.
changes:
WELL AT TOTAL DEPTH (PROPOSED)
WELL AT SURFACE
12. LEASE NO.
17. LEASE NO. and FACILITY NAME
13. AREA NAME
18. AREA NAME
14. BLOCK NO.
19. BLOCK NO.
15. LATITUDE
16. LONGITUDE
20. LATITUDE
21. LONGITUDE
(
NAD 83 /
NAD 27)
(
NAD 83 /
NAD 27)
(
NAD 83 /
NAD 27)
(
NAD 83 /
NAD 27)
LIST OF SIGNIFICANT MARKERS ANTICIPATED
22. NAME
23. TOP (MD)
24. TOP (TVD)
22. NAME
23. TOP (MD)
24. TOP (TVD)
25. LIST ALL ATTACHMENTS (Attach complete well prognosis + attachments required by 30 CFR 250.414 or 30 CFR 250.1617(c) and (d) as appropriate.)
26. CONTACT NAME
27. CONTACT TELEPHONE NO.
28. CONTACT E-MAIL ADDRESS
CERTIFICATION: I certify that information submitted is complete and accurate to the best of my knowledge. I understand that making a false statement
may subject me to criminal penalties under 18 U.S.C. 1001 (signature in # 31. below).
29. AUTHORIZING OFFICIAL (Type or print name)
30. TITLE
31. AUTHORIZING SIGNATURE
32. DATE
THIS SPACE FOR BSEE USE ONLY
APPROVED:
BY
TITLE
With Attached Conditions
Without Conditions
DATE
API WELL NO. ASSIGNED TO THIS WELL
BSEE
FORM BSEE-0123 (June 2020 - Supersedes all previous versions of this form which may not be used). Page 1 of 2
U.S. Department of the Interior
OMB Control No. 1014-0025 OMB
Submit original plus THREE copies,
Bureau of Safety and Environmental
Approval Expires 06/30/2023
with ONE copy marked "Public Information."
Enforcement (BSEE)
Application for Permit to Drill (APD)
PROPOSAL TO DRILL
1.
2. BSEE OPERATOR NO.
3. OPERATOR NAME and ADDRESS
NEW WELL
SIDETRACK
DEEPEN
BYPASS
(Submitting office)
4. WELL NAME (CURRENT)
5. SIDETRACK NO. (CURRENT)
6. BYPASS NO. (CURRENT)
7. PROPOSED START DATE
8. PLAN CONTROL NO. (NEW WELL ONLY)
9. API WELL NO. (CURRENT SIDETRACK / BYPASS) (12 DIGITS)
If revision, list
10.
Revision
11.
changes:
WELL AT TOTAL DEPTH (PROPOSED)
WELL AT SURFACE
12. LEASE NO.
17. LEASE NO. and FACILITY NAME
13. AREA NAME
18. AREA NAME
14. BLOCK NO.
19. BLOCK NO.
15. LATITUDE
16. LONGITUDE
20. LATITUDE
21. LONGITUDE
(
NAD 83 /
NAD 27)
(
NAD 83 /
NAD 27)
(
NAD 83 /
NAD 27)
(
NAD 83 /
NAD 27)
LIST OF SIGNIFICANT MARKERS ANTICIPATED
22. NAME
23. TOP (MD)
24. TOP (TVD)
22. NAME
23. TOP (MD)
24. TOP (TVD)
25. LIST ALL ATTACHMENTS (Attach complete well prognosis + attachments required by 30 CFR 250.414 or 30 CFR 250.1617(c) and (d) as appropriate.)
26. CONTACT NAME
27. CONTACT TELEPHONE NO.
28. CONTACT E-MAIL ADDRESS
CERTIFICATION: I certify that information submitted is complete and accurate to the best of my knowledge. I understand that making a false statement
may subject me to criminal penalties under 18 U.S.C. 1001 (signature in # 31. below).
29. AUTHORIZING OFFICIAL (Type or print name)
30. TITLE
31. AUTHORIZING SIGNATURE
32. DATE
THIS SPACE FOR BSEE USE ONLY
APPROVED:
BY
TITLE
With Attached Conditions
Without Conditions
DATE
API WELL NO. ASSIGNED TO THIS WELL
BSEE
FORM BSEE-0123 (June 2020 - Supersedes all previous versions of this form which may not be used). Page 1 of 2
Application for Permit to Drill (APD) Information Sheet
33) Question Information Sheet
Questions
Response
Remarks
YES
A) Will you maintain quantities of mud and mud material
NO
(including weight materials and additives) sufficient to raise the
N/A
entire system mud weight 1/2 ppg or more?
YES
B) If hydrocarbon-based drilling fluids were used, is the drilling
rig outfitted for zero discharge and will zero discharge
NO
procedures be followed?
N/A
YES
C) If drilling the shallow casings strings riserless, will you
NO
maintain kill weight mud on the rig and monitor the wellbore
with an ROV to ensure that it is not flowing?
N/A
YES
D) If requesting a waiver of the conductor casing, have you
NO
submitted a log to BSEE District Office that is with in 500 feet
N/A
of the proposed bottom hole location for the proposed surface
casing point?
E) Will the proposed operation be covered by an EPA
YES
Discharge Permit? (please provide permit number in remarks
NO
for this question)
N/A
YES
F) Will all wells in the well bay and related production
equipment be shut-in when moving on to or off of an offshore
NO
platform, or from well to well on the platform? If not, please
N/A
explain.
YES
G) Is the calculated daily volume possible from an
uncontrolled blowout of this well greater than the daily volume
NO
included in the worst case discharge scenario in the approved
N/A
oil spill response plan?
YES
H) Has the drilling rig been approved for the use of digital BOP
NO
testing? If yes, which version?
N/A
PAPERWORK REDUCTION ACT OF 1995 (PRA) STATEMENT: The PRA (44 U.S.C. 3501 et seq ) requires us to inform
you that we collect this information to obtain knowledge of equipment and procedures to be used in drilling operations. BSEE
uses the information to evaluate and approve or disapprove the adequacy of the equipment and/or procedures to safely
perform the proposed drilling operation. Responses are mandatory (43 U.S.C. 1334). Proprietary data are covered under 30
CFR 250.197. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB Control Number. The burden to fill out Forms BSEE-0123 + BSEE-0123S is
estimated at 1 hour per response. This burden represents only the filling out of the forms, the burden for the attachments
required range from 30 minutes to 2,800 hours depending on the region and the requirement. Direct comments regarding the
burden estimate or any other aspect of this form to the Information Collection Clearance Officer, Bureau of Safety and
Environmental Enforcement, 45600 Woodland Road, Sterling, VA 20166.
BSEE
FORM BSEE-0123
(June 2020 - Supersedes all previous versions of this form which may not be used). Page 2 of 2
Page of 2