Form Dnr 5619 - Application For A Permit

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OHIO DEPARTMENT OF NATURAL RESOURCES

DIVISION OF OIL AND GAS RESOURCES MANAGEMENT

2045 MORSE RD., BLDG. F-2, COLUMBUS, OH 43229-6693

Phone: (614) 265-6922 • Fax: (614) 265-6910

APPLICATION FOR A PERMIT (Form 1)

(REVISED 0915)

SEE INSTRUCTIONS ON BACK

1. We (applicant) __________________________________________________________________

OWNER NUMBER:

Address: _______________________________________________________________________

Phone Number: (

)

–

hereby apply this date ___________________________________, 20_______ for a permit to:

Drill Vertical Well

Revised Location

Convert

Drill Horizontally

Plug Back

Deepen

Drill Directionally

Plug and Abandon

Reopen

Reissue

Temporary Inactive:

year

_____

year

TYPE OF WELL:

Oil & Gas

Annular Disposal

Saltwater Injection

Stratigraphic Test

Gas Storage

Other (explain):

Solution Mining*

Enhanced Recovery* (*if checked, select appropriate box below)

Input/Injection

Water Supply

Observation

Production/Extraction

4. Is the well location or production facility(s)

20.

TYPE OF TOOLS:

within an urbanized area as defined by ORC

Cable

Rotary (

Air

Fluid)

1509.01 (Y)?

Yes

Cable/Rotary

Service Rig

21.

MAIL PERMIT TO:

SOURCE(S) OF GROUND AND/OR SURFACE WATER USED IN PRODUCTION OPERATION:

––––––––––––––––––––––––––––––––––––––––––––––––––––––-----––––––––––––––

Watershed:

Lake Erie

Ohio River

Estimated Withdrawal Rate (gal/day):

COUNTY:

(Select County)

Estimated Total Volume (gal):

CIVIL TOWNSHIP:

If Recycled Water – Estimated Total Volume (gal):

SECTION:

LOT:

10.

11.

22.

(closest to well site):

FRACTION:

QTR TWP:

EMERGENCY TELEPHONE NUMBERS

12.

Fire:

TRACT/ALLOT:

13.

Medical:

WELL NUMBER:

14.

23.

LEASE NAME:

MEANS OF INGRESS AND EGRESS:

15.

Road:

PROPOSED TOTAL DEPTH:

16.

24.

PROPOSED GEOLOGICAL FORMATION(S):

ROAD USE FOR HORIZONTAL WELL:

_________________________________________

Maintenance Agreement Attached

_________________________________________

Non-agreement Affidavit Attached

_________________________________________

State Route (Not Required)

17.

25.

DRILLING UNIT ACRES:

ARE THE SURFACE RIGHTS OWNED BY THE STATE OF OHIO?

Agency Name:

18.

ATTACH LANDOWNER ROYALTY LISTING:

19.

26.

Date of Last Production:

IF PERMITTED PREVIOUSLY:

FOR PLUGGING APPLICATIONS:

API Number:

Amount of Oil: ______________________ (bbl) Gas: _______________________ (mcf)

27.

PROPOSED CASING AND CEMENTING PROGRAM

Borehole

Casing

Cement

Zone Tested

Hydraulic

Diameter

Depth

Diameter

Depth

Volume

or Produced

Fracturing

Type Casing

(in)

(ft)

(in)

(ft)

(sacks)

Formation

(ü if Yes)

Drive Pipe

Conductor

Mine String

Surface

Intermediate

Production

Liner

I, the undersigned, being first duly sworn, depose and state under penalties of law, that I am authorized to make this application, that this application was prepared by me or under my supervision and

direction, and that the facts stated herein are true, correct, and complete, to the best of my knowledge.

I, the undersigned, further depose and state that I am the person who has the right to drill on the tract or drilling unit and to drill into and produce from a pool and to appropriate the oil or gas that I produce therefrom

either for myself or others as described in this application. And furthermore, I the undersigned, being duly sworn, depose and state at this time that I am not liable for any final nonappealable order of a court for damage

to streets, roads, highways, bridges, culverts, or drainage ways pursuant to Section 5577.12 of the Ohio Revised Code (ORC). I, the undersigned, further depose and state that all notices required by 1509.06 (A) (9)

ORC for this application have been duly provided by me. If applying for a permit to plug and abandon a well, I hereby certify that the written notices, as required in Section 1509.13, ORC, have been given.

That I hereby agree to conform with all provisions of Chapter 1509., ORC, and Chapter 1501., OAC, and all orders and conditions issued by the Chief, Division of Oil and Gas Resources Management.

Signature of Owner/Authorized Agent: ____________________________________________________________________________________________________

Name (Type or Print): _______________________________________________________________ Title: ______________________________________________

___________________________________________________________ if signed by Authorized Agent, a certificate of appointment of agent must be on file.

Sworn to and subscribed before me this the ________ day of __________________________________________, 20 _______ .

___________________________________________________

(Notary Public)

___________________________________________________

(Date Commission Expires)

DNR 5619 (REVISED 0915)