FORM
WW-9
Page _______ of ________
Rev. 02/01
API Number 47 - ________ -
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Operator's Well No._____________________
STATE OF WEST VIRGINIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION,
OFFICE OF OIL AND GAS
CONSTRUCTION AND RECLAMATION PLAN AND
SITE REGISTRATION APPLICATION FORM
GENERAL PERMIT FOR OIL AND GAS PIT WASTE
DISCHARGE
Operator
Name______________________________________________________
OP Code _________________________
Watershed____________________________________________
Quadrangle _____________________________________
Elevation
__________________________ County___________________________
District_________________________
Description of anticipated
Pit Waste: ______________________________________________________________________
Will a synthetic liner be
used in the pit? ________________.
Proposed Disposal Method For
Treated Pit Wastes:
______ Land Application
______ Underground Injection
( UIC Permit Number__________________________________________)
______ Reuse
(at API
Number____________________________________________________________)
______ Off Site Dispposal (Supply form WW-9 for disposal location)
______ Other
(Explain___________________________________________________________________
Proposed Work For Which Pit
Will Be Used:
______ Drilling
_______ Swabbing
______ Workover
_______ Plugging
______ Other
(Explain___________________________________________________________________
_____________________________________________________________________________________________________
I certify that I understand and agree to the terms and conditions of the
GENERAL WATER POLLUTION PERMIT issued on December 31, 1999, by the Office of Oil
and Gas of the West Virginia Department of Environmental Protection.
I understand that the provisions of the permit are enforceable by law.
Violations of any term or condition of the general permit and/or other
applicable law or regulation can lead to enforcement action.
I certify under penalty of law that I have personally examined and am
familiar with the information submitted on this application form and all
attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining the information, I believe that the
information is true, accurate, and complete.
I am aware that there are significant penalties for submitting false
information, including the possibility of fine or imprisonment.
Company Official
Signature______________________________________________________________________________
Company Official
(Typed
Name)__________________________________________________________________________
Company Official
Title__________________________________________________________________________________
___________________________________________________________________________________________________
Subscribed and sworn before
me this_____________ day of__________________________,
19_______
_______________________________________________________________________
Notory Public
My commission
expires_________________________________________________________________
LEGEND
Property Boundary
Diversion
Road
Spring
Existing Fence
Wet Spot
Planned Fence
Drain Pipe with size in inches
Stream
Waterway
Open Ditch
Cross Drain
Rock
Artificial Filter Strip
North
Pit: cut walls
Buildings
Pit: compacted fill walls
Water wells
Area for Land Application of Pit Waste
Drill site
_____________________________________________________________________________________________________
Proposed Revegetation
Treatment: Acres Disturbed
_______________________ Prevegetation
pH ____________________
Lime _______________ Tons/acre or to correct to pH
___________________
Fertilizer (10-20-20 or equivalent) _____________lbs/acre (500 lbs
minimum)
Mulch_________________________________Tons/acre
Seed
Mixtures
Area
I
Area II
Seed Type
lbs/acre
Seed Type
lbs/acre
______________________________________________
_______________________________________________
______________________________________________
_______________________________________________
______________________________________________
_______________________________________________
_____________________________________________________________________________________________________
Attach:
Drawing(s) of road,
location,pit and proposed area for land application.
Photocopied section of
involved 7.5' topographic sheet.
_____________________________________________________________________________________________________
Plan Approved
by:______________________________________________________________________________________
Title:___________________________________________
Date:__________________________________________
Field Reviewed?
(________) Yes
(_________) No
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WW4-A |
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Revised |
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Operator’s Well Number |
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2/01 |
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3) API Well No.: 47 - |
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DEPARTMENT OF ENVIRONMENTAL PROTECTION,
OFFICE OF OIL AND GAS
NOTICE 0F APPLICATION TO PLUG AND
ABANDON A WELL
4)
Surface Owner(s) to be served:
5) (a) Coal Operator
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__________________________________________________________________________________________
TO THE PERSONS NAMED
ABOVE: You should have received this Form and the following
documents:
(1)
The application to Plug and Abandon a Well on Form WW-4B, which sets out
the parties involved in the work and describes the well its and the plugging
work order; and
(2)
The plat (surveyor’s map) showing the well location on Form WW-6.
The reason you received these documents is that you have rights
regarding the application which are summarized in the instructions on the
reverses side. However, you are not
required to take any action at all.
Take notice that under Chapter 22-6 of the West Virginia Code, the undersigned well operator proposes to file or has filed this Notice and Application and accompanying documents for a permit to plug and abandon a well with the Chief of the Office of Oil and Gas, West Virginia Department of Environmental Protection, with respect to the well at the location described on the attached Application and depicted on the attached Form WW-6. Copies of this Notice, the Application, and the plat have been mailed by registered or certified mail or delivered by hand to the person(s) named above (or by publication in certain circumstances) on or before the day of mailing or delivery to the Chief.
__________________________________________________________________________________________
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Subscribed
and sworn before me this __________ day
of ___________________________________
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Notary
Public |
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My
Commission Expires |
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FORM WW-4(B)
1)Date______________, 19______
Observe
2)Operator's
File Copy
Well No.____________________
(Rev.
2/01)
3)API Well No. 47-______-_________
STATE OF WEST VIRGINIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OFFICE OF OIL AND GAS
APPLICATION FOR A PERMIT TO PLUG AND ABANDON
4)
Well Type: Oil _____/ Gas
_____/ Liquid injection _____/ Waste disposal _____/
(If
"Gas, Production ____ or Underground storage ____) Deep ____/ Shallow____
5) Location:
Elevation___________________ Watershed___________________________________
District ___________________ County___________
Quadrangle________________
6) Well Operator
_________________________ 7)Designated
Agent__________________________
Address
_________________________
Address__________________________
_________________________
__________________________
8) Oil and Gas
Inspector to be notified
9)Plugging Contractor
Name________________________________ Name_________________________________
Address_____________________________ Address______________________________
_____________________________
______________________________
__________________________________________________________________________________________
10)
Work Order: The work order
for the manner of plugging this well is as follows:
Notification must be given to the district oil and gas inspector 24 hours before permitted work can commence.
Work
order approved by inspector _______________________________ Date __________________
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The well operator named on page WW-4A is applying for a permit from the
State to plug and abandon a well. (Note:
If the surface tract is owned by more than three persons, then these materials
were served on you because your name appeared on the Sheriff’s tax ticket on
the land or because you actually occupy the surface tract.
In either case, you may be the only owner who will actually receive these
materials.) See Chapter 22 of the
West Virginia Code. Well work
permits are valid for 24 months. If
you do not own any interest in the surface tract, please forward these materials
to the true owner immediately if you know who it is.
Also, please notify the well operator and the Office of Oil and Gas.
NOTE: YOU ARE NOT REQUIRED TO FILE ANY
COMMENT.
WHERE TO FILE COMMENTS AND OBTAIN
ADDITIONAL INFORMATION:
Chief,
Office of Oil and Gas
Department
of Environmental Protection
1356
Hansford Street
Charleston,
WV 25301
(304)
558-6342
Time Limits and methods for filing comments.
The law requires these materials to be served on or before the date the
operator files his Application. You
have FIVE (5) DAYS after the filing date to file your comments.
Comments must be filed in person or received in the mail by the Chief’s
office by the time stated above. You
may call the Chief’s office to be sure of the date.
Check with your postmaster to ensure adequate delivery time or to arrange
special expedited handling. If you
have been contacted by the well operator and you have signed a “voluntary
statement of no objection” to the planned work described in these materials,
then the permit may be issued at any time.
Comments must be in writing. Your comments must include your name, address and telephone
number, the well operator’s name and well number and the approximate location
of the proposed well site including district and county from the application.
You may add other documents, such as sketches, maps or photographs to
support your comments.
The Chief has the power to deny or condition a well work permit based on
comments on the following grounds:
1)
The proposed well work will
constitute a hazard to the safety of persons.
2)
The soil erosion and sediment
control plan is not adequate or effective;
3)
Damage would occur to publicly
owned lands or resources;
4)
The proposed well work fails to
protect fresh water sources or supplies;
5)
The applicant has committed a
substantial violation of a previous permit or a substantial violation of one or
more of the rules promulgated under Chapter 22, and has failed to abate or seek
review of the violation…”.
If you want a copy of the permit as it is issued or a copy of the order
denying the permit, you should request a copy from the Chief.
VOLUNTARY STATEMENT OF NO OBJECTION
I hereby state that I have read the
instructions to surface owners and that I have received copies of a Notice and
Application For A Permit To Plug And Abandon on Forms WW-4A and WW-4B, and a
survey plat.
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.
FOR
EXECUTION BY A NATURAL PERSON
FOR EXECUTION BY A CORPORATION, ETC.
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Signature
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FORM
WW-4 (B)
API No.
Farm Name
Well No.
The
well operator named on the obverse side of WW-4 (B) is about to abandon the well
described in the enclosed materials and will commence the work of plugging and
abandoning said well on the date the inspector is notified.
Which date shall not be less then five days after the day on which this
notice and application so mailed is received, or in due course should be
received by the Department of Environmental Protection Office of Oil & Gas.
This notice and application is given to you in order that your respective
representatives may be present at the plugging and filling of said well.
You are further notified that whether you are represented or not the
operator will proceed to plug and fill said well in the manner required by
Section 24, Article 6, Chapter 22 of the Code and given in detail on obverse
side of this application.
NOTE: If you wish this well
to be plugged according to 22-6-24(d) then as per Regulation 35CSR4-13.9 you
must complete and return to this office on form OB-16 “Request by Coal
Operator, Owner, or Lessee for plugging” prior to the issuance of this
plugging permit.
WAIVER
The
undersigned coal operator _____/ owner _____/ lessee _____/ of the coal under
this well location has examined this proposed plugging work order.
The undersigned has no objection to the work proposed to be done at this
location, provided, the well operator has complied with all applicable
requirements of the West Virginia Code and the governing regulations.
Date: ____________________
______________________________________
By: ___________________________________
Its ___________________________________
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