WW-6AW
API NO. 47-______-________________
(1-12)
OPERATOR WELL NO. ____________
Well Pad Name: ____________________
STATE OF WEST VIRGINIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION, OFFICE OF OIL AND GAS
VOLUNTARY STATEMENT OF NO OBJECTION
Instructions to Persons Named on Page WW-6A
The well operator named on page WW-6A is applying for a permit from the State of West Virginia to conduct oil or gas well work.
Well work permits are valid for twenty-four (24) months. Please contact the listed well operator and the Office of Oil and Gas if you
do not own any interest in the listed surface tract.
Comment and Waiver Provisions
Pursuant to West Virginia Code § 22-6A-11(a), all persons described in subsection (b), section ten of this article may file written
comments with the secretary as to the location or construction of the applicant's proposed well work within thirty days after the
application is filed with the secretary.
Pursuant to West Virginia Code § 22-6A-8(b) No permit may be issued less than thirty days after the filing date of the application for
any well work except plugging or replugging; and no permit for plugging or replugging may be issued less than five days after the
filing date of the application except a permit for plugging or replugging a dry hole: Provided, That if the applicant certifies that all
persons entitled to notice of the application under the provisions of subsection (b), section ten of this article have been served in
person or by certified mail, return receipt requested, with a copy of the well work application, including the erosion and sediment
control plan, if required, and the well plat, and further files written statements of no objection by all such persons, the secretary may
issue the well work permit at any time.
VOLUNTARY STATEMENT OF NO OBJECTION
I, _______________________, hereby state that I have read the Instructions to Persons Named on Page WW-6A and the associated
provisions listed above, and that I have received copies of a Notice of Application, an Application for a Well Work Permit on Form
WW-6A and attachments consisting of pages one (1) through ___________, including the erosion and sediment control plan, if
required, and the well plat, all for proposed well work on the tract of land as follows:
State:
Easting:
UTM NAD 83
County:
Northing:
District:
Public Road Access:
Quadrangle:
Generally used farm name:
Watershed:
I further state that I have no objection to the planned work described in these materials, and I have no objection to a permit being
issued on those materials.
*Please check the box that applies
FOR EXECUTION BY A NATURAL PERSON
□
SURFACE OWNER
Signature: ________________________________
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Print Name: ______________________________
SURFACE OWNER (Road and/or Other Disturbance)
Date: ____________________________________
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SURFACE OWNER (Impoundments/Pits)
FOR EXECUTION BY A CORPORATION, ETC.
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COAL OWNER OR LESSEE
Company:_________________________________
By: ______________________________________
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COAL OPERATOR
Its: ______________________________________
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WATER PURVEYOR
Signature: ________________________________
□
Date: ____________________________________
OPERATOR OF ANY NATURAL GAS STORAGE FIELD
Oil and Gas Privacy Notice:
The Office of Oil and Gas processes your personal information, such as name, address and telephone number, as part of our regulatory
duties. Your personal information may be disclosed to other State agencies or third parties in the normal course of business or as
needed to comply with statutory or regulatory requirements, including Freedom of Information Act requests. Our office will
appropriately secure your personal information. If you have any questions about our use or your personal information, please contact
DEP’s Chief Privacy Officer at depprivacyofficer@wv.gov.