Well Operator'S Annual Inspection Form
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1OP-13
(Rev. 12-15)
STATE OF WEST VIRGINIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OFFICE OF OIL AND GAS
WELL OPERATOR’S ANNUAL INSPECTION FORM
API NUMBER
WELL OPERATOR
FARM NAME
WELL NUMBER
COUNTY
Question
Yes
No
( )
( )
1.
Is the location free of oil/gas/saltwater leaks?
( )
( )
2.
Is the annulus between the surface and production casing sealed?
( )
( )
3.
Is the annulus free from escaping gas or fluid?
( )
( )
4.
Is down hole free from escaping gas or fluid?
( )
( )
5.
Is there any evidence of groundwater contamination?
( )
( )
6.
Are the appropriate water and sediment controls in place and working properly
including vegetation coverage regarding both the well location and access road?
( )
( )
7.
Is the well connected to a storage tank? If Yes, answer the questions below.
( )
( )
8.
Are tanks registered with the Aboveground Storage Tanks (AST) Program?
Is the AST tank registration number, Department of Environmental Protection’s
( )
( )
9.
Spill Reporting Hotline number and emergency contact number marked on each
tank or on sign near it?
( )
( )
10.
Are tanks secured and properly maintained?
( )
( )
11.
Are tank drain-lines secured and properly maintained?
( )
( )
12.
Are tanks in the battery manifolded?
( )
( )
13.
Is the secondary containment large enough to contain the contents of the single
largest tank per battery?
( )
( )
14.
Do the tanks have secondary containment structures?
( )
( )
15.
Are the secondary containment structures adequate?
( )
( )
16.
Are manifolded tanks protected by valving, locks, etc. to prevent multiple tanks
from being drained from a single leaking tank?
( )
( )
17.
Are the containment structure walls constructed with materials that are impervious?
( )
( )
18.
Are the containment structures free from water/oil?
( )
( )
19.
Do the secondary containment structures have drains?
( )
( )
20.
Are drains in the secondary containment structures closed and plugged?
( )
( )
21.
Is salt water being properly disposed?
This form should be completed for each well for which an annual inspection is conducted as
required by WV Legislative Rule § 35-4-11.6 or § 35-8-9.2j. Certification of the performance of
the annual inspection must be made in conjunction with the operator's annual report.
Date:
Signature:
Printed Name:
Title:
RETAIN FOR YOUR FILE. DO NOT SUBMIT TO WVDEP.
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