MISCELLANEOUS APPLICATION - OIL OR GAS WELL

STATE OF OREGONDEPT OF GEOLOGY MINERAL INDUSTRIES 229 BROADALBIN ST SW  ALBANY OR 97321

(In compliance with rules and regulations pursuant to ORS 520.)

(1) Permittee Information(2) Well Information

Name / Well Name
Mailing Address / DOGAMI ID No.
City/State/Zip
Telephone / (3) Proposed Work & Fee Required
Fax / Extend period to complete drilling / $500
Email / Deepen / $1,500
Prepared by / Rework / $1,500
On Site Contact / Plug & Abandon / $1,000
Phone (day) / Sidetrack / $500
Phone (night)
Other

SignatureTitleDate

(4) Present Condition of Well

Size of hole / Size of Casing / Weight in pounds per foot / Grade/Type / Depth / Cemented Interval / Perforations (number and depth) / Tubing detail (type and location)

(5) Wellhead Pressure (psi)

(6) Detailed account of proposed work. (For P&As, describe the abandonment and site reclamation plan.)

(7) P&A Design

Type of Cement / Cement Additives
Type% by weight / Location of Plugs
(Intervals) / Capacity of Plugging Interval / Volume of Cement / Excess Volume of Cement
% by weight / ft. / bbls/ft. / bbls / bbls
% by weight / ft. / bbls/ft. / bbls / bbls
% by weight / ft. / bbls/ft. / bbls / bbls
% by weight / ft. / bbls/ft. / bbls / bbls

MISCELLANEOUS APPLICATION - OIL OR GAS WELL

STATE OF OREGONDEPT OF GEOLOGY MINERAL INDUSTRIES 229 BROADALBIN ST SW  ALBANY OR 97321

(In compliance with rules and regulations pursuant to ORS 520.)

INSTRUCTIONS & REQUIREMENTS

A complete application is required to deepen, rework, abandon, or any other proposed procedureon an existing well.

A complete application consists of:

  1. This completed application form. We must have original signatures for our records.
  2. The $appropriate application fee.
  3. Drilling bond, if applicable.

The application will be reviewed to determine if it is required to be circulated to other agencies for review.

OAR 632-010-0010(6)(a) states that the State Geologist shall circulate each application for a permit to drill for technical review to appropriate state agencies and the governing body of the county or city in which the well will be located. The agencies and governing body have twenty (20) days from the date of application in which to comment; (b) The State Geologist may approve immediately without circulating for technical review an application for a permit to redrill, deepen, or rework if operations are an uninterrupted continuance of previous operations, provided conditions of OAR 632-010-0142(3) are met.

The permit will be issued after completion of the review process, if a review is required, otherwise the permit may be issued immediately.

MISCELLANEOUS APPLICATION - OIL OR GAS WELL.DOC

REV. 12/14/2007