Fillable Printable Form 2109
Fillable Printable Form 2109
Form 2109
APPLICATION FOR WELL PERMIT
State Form 21096 (R2 / 8-12) / Form A1
Approved by State Board of Accounts, 2012
INDIANA DEPARTMENT OF NATURAL RESOURCES
Division of Oil and Gas
402 W. Washington St., Rm. 293
Indianapolis, IN 46204
Telephone number: (317) 232-4055
FAX number: (317) 232-1550
Internet: //www.in.gov/dnr/dnroil
FOR STATE USE ONLY
Application number
Permit number
Date received
Date approved
IGS ID No.
Approved by
IGS Samples
Yes No
IGS Pool Name
PART I GENERAL INFORMATION
Name of operator
Telephone number
( )-
FAX number
( )-
Address of operator(Street or PO Box)( Check here if this is a new address )
City
State
ZIP code
-
Send permit to(Enter name and address)
Telephone number
( ) -
FAX number
( )-
Check here if you would like to have the permit sent via FAX or email. Email address: @
Expedite: Please check here and submit a total permit fee of $750 to request 2 day processing
NOTE: Expediting not available for Class II and Non commercial gas applications
Applicant is (Check one only) Individual Partnership Public corporation
Limited liability company Corporation Limited partnership
NOTE: Corporations, limited partnerships and limited liability companies must register with the Secretary of
State. For further information about registration, contact the Corporations Division, Secretary of State at
(317) 232-6576
Type of bond (Check one only)
Surety bond
Blanket bond
Certificate of deposit
Check
Personal surety bond (Valid for Non-commercial gas wells only)
Bond not required per IC 14-37-6-1
NOTES: A bond must accompany this application unless the operator has a valid blanket bond on file with the
division or is exempt from bonding under IC 14-37-6-1. All bonds must be originals and an original Verification
of Certificate of Deposit form must accompany CD’s. Checks must be certified. The bond amount for individual
wells is $2,500 and for blanket bonds is $45,000.
Well type (Check one only)
Oil (Complete PARTS I thru IVa, VI and VII)
Gas (Complete PARTS I thru IVa, VI and VII)
Coal Bed Methane (Complete PARTS I thru IVa, VI and VII and Submit Form A12 – Coal Owner Affidavit and Consent)
Class II Enhanced Recovery (Complete PARTS I, II, IVb, V,VI, and VII)
Class II Saltwater Disposal (Complete PARTS I, II, IVb, V,VI, and VII)
Non-commercial gas (Complete PARTS I thru IVa, VI and VII)
Geologic/ Structure test (Complete PARTS I, II, IVa, VI, and VII)
Gas storage or observation (Complete PARTS I thru IVa, IVc, VI, and VII)
Non potable water supply (Complete PARTS I thru IVa, IVd, VI, and VII)
Dual completion for Oil and Class II injection only (Complete PARTS I thru IVb, V, VI, and VII)
Dual completion for Gas and Class II injection only (Complete PARTS I thru IVb, V, VI, and VII)
Application type (Check no more than two)
New well
Old well workover
Old well deepening
Horizontal well sidetracking
Conversion
Change of location
Change of operator (Complete PARTS I, II, VI and VII indicating lease
lines and drilling unit boundaries, only unless another application type is also
checked)
Permit renewal (Complete PARTS I, II and VI only unless another
application type is also checked)
Note: A $250 permit fee is required except for expedited permits, which
require a $750 fee.
Fee Payment Method: Check Credit Card (Attach credit card information on separate page or provide
contact number: ( )-
Former operator (If applicable)
Former Permit number (If applicable)
Continued on next page
Reset Form
PART II SURFACE LOCATION AND LEASE INFORMATION
Name of lease
Well number
Elevation (G.L.)
Township
Range
Land Type
Land Number:
¼
¼
¼
Footages: ft. from N, S, NW, SE line
ft. from
E,W, NE, SW line
County
Distance to the nearest well capable of production from the same zone in which this well will be
completed: feet
Drilling unit acreage (Check one only)
5 acres 20acres
10 acres 40 acres
NRC Bulletin 58: acres (Include map of waterflood
or voluntary pooling unit)
Other acres (Attach unit exception or petition for
exception and supporting documentation)
Check here if acreage is communitized (pooled)
NOTE: Attach a copy of the unit agreement or declaration
of pooling. If previously submitted identify the permit
number under which it was submitted:
Permit No.
Lease acreage
Acres
Does operator own or control the rights to drill and produce oil and/or natural gas or coal bed methane in and
under all land(s) within the drilling unit boundary and the lease acreage herein indicated and shown on the
attached Survey?
Yes No If No, explain the basis upon which the operator claims the right to drill and
produce oil and/or natural gas and/or coal bed methane under this permit:
Yes No
Does this application include a Notice of Intent to Survey and proof of delivery to the surface owner?
Name of Surface Owner:
PART III PROPOSED WELL CONSTRUCTION
Check here and go to PART IV if the well presently exists and the construction will not change
Enter casing strings from largest to smallest and enter the cement information on successive rows for a casing string that will be set using
multiple cement stages.
Casing Information Cementing Information
Casing
Size (OD)
Casing Type Casing
Bottom
Casing
Top
Hole
Size
Cement Type Cement
Volume
Volume
Type
Cement
Yield
ft. ft.
ft. ft.
ft. ft.
ft. ft.
Packer setting depth ft.
Packer setting depth ft.
Packer setting depth ft.
Centralizers at
ft. ft. ft. ft.
Casing perforated From ft. to ft.
From ft. to ft.
From ft. to ft.
From ft. to ft.
PART IV DRILLING AND OPERATIONAL INFORMATION
Section a All Wells
Declination type (Check one only) Note: For Directional & Horizontal wells the surface sp o t an d
Vertical Directional Horizontal termination point of the well must be shown on the survey.
Proposed total vertical depth feet (All wells) Proposed measured length feet (Horizontal wells only)
Name of deepest formation to be drilled
Pool (Name): Or Wildcat
Section b Injection Wells
Proposed Maximum Injection Pressure (MIP) measured in PSI at
the wellhead
Proposed injection rate measured in barrels of water per day
NOTE: Calculated Maximum Injection Pressure (MIP) is based on the formula (0.8 psi/ft.-(0.433 psi/ft. (specific gravity)))depth. If you are
applying for a MIP that is greater than the calculated MIP you must submit the results of: 1. A service company acid or fracture job that shows
an instantaneous shut in pressure (ISIP), or 2. A service company step rate test that has a minimum of 3 steps and a breakdown pressure.
The data must be for the injection formation, come from a well that is located in the same field as the injection well, and be less than 10 years
old to be considered.
Section c Gas Storage/ Observation Wells
Injection/ withdrawal interval From. ft. to ft
Injection/ withdrawal formation
Observation interval From. ft. to ft
Observation formation
Section d Non Potable Water Supply Wells
Withdrawal amount (Gallons per day)
Water withdrawal interval From. ft. to ft
Withdrawal formation
Continued on the next page
>Select One<
PART V PROPOSED WELL DIAGRAM
NOTE: This diagram is required only for Class II injection and Dual Completion wells.
WELL CONSTRUCTION
Surface casing
Setting depth feet
Size (OD) in.
Hole size in.
Cement top feet
Cubic feet
Intermediate casing
Setting depth feet
Size (OD) in.
Hole size in.
Cement top feet
Cubic feet
Long string
Setting depth feet
Size (OD) in.
Hole size in.
Cement top feet
Cubic feet
Liner
Setting depth feet
Size (OD) in.
Hole size in.
Cement top feet
Cubic feet
Centralizers
ft
ft
ft
ft
Cement squeeze
Perf. From ft. to ft
Cubic feet
Tubing
Setting depth feet
Size (OD) in
Packers
Setting depth feet
Setting depth feet
Setting depth feet
Perforations
From ft. to ft
From ft. to ft
From ft. to ft
From ft. to ft
GEOLOGIC INFORMATION
Production zones (Top to bottom)
Name
Intervals From to ft.
Primary lithology (Check one)
Sandstone Limestone
Name
Intervals From to ft.
Primary lithology (Check one)
Sandstone Limestone
Name
Intervals From to ft.
Primary lithology (Check one)
Sandstone Limestone
Confining zone
Name
Intervals From to ft.
Primary lithology (Check one)
Shale Limestone
Injection zones (Top to bottom)
Name
Intervals From to ft.
Primary lithology (Check one)
Sandstone Limestone
Name
Intervals From to ft.
Primary lithology (Check one)
Sandstone Limestone
Name
Intervals From to ft.
Primary lithology (Check one)
Sandstone Limestone
Name
Intervals From to ft.
Primary lithology (Check one)
Sandstone Limestone
Plugback depth feet
Plugback type (Check all that apply)
CIBP Cement
Other (Explain below )
Total depth feet
Continued on next page
PART VI AFFIRMATION
I affirm under penalty of perjury that the information provided in this application is true to the best of my knowledge and belief.
Typed or printed name of operator or authorized agent
Signature of operator or authorized agent
Date signed (month , day, year)
SPECIAL REQUIREMENTS
1. Only those individuals whose signatures appear in PARTS V and VI of the Organizational Report may sign this form.
2. The name of the operator on this application and the name of the principal on the bond must be identical.
3. If you are applying for a Change of Operator permit you are certifying that you have conducted a good faith search for the
current operator and said operator could not be located.
4. If you are applying for a new well permit, do not forget to include the Notice of Intent to Survey and proof of service required
under IC 32-23-7-6.5 that must be sent to the surface owner at least five (5) days prior to entering onto the property for the
purpose of surveying the well location. An example of the notice is available on the division’s website under
Publications/Notices and Examples.
APPLICATION REMINDERS
PART I:
Enter the name of the operator exactly as it appears on the Organizational Report.
If you want to have a copy of the permit certificate faxed to you please check the appropriate box.
If you want to request an expedited permit please check the appropriate box and attach a $750 permit fee.
Don’t forget to register with the Indiana Secretary of State if you will operate as a Corporation, Limited Liability Company or
Limited Partnership.
Don’t forget to attach the $250 permit fee or $750 permit fee for expedited permits.
If a Certificate of Deposit is selected as the Bond Type, don’t forget to attach the original CD and original Verification of
Certificate form.
PART II
If the well will be an oil, gas or coal bed methane well be sure to indicate the distance to the nearest well capable of production
from the same formation for which this permit is to be issued and make sure you check the rule requirements on well spacing
to avoid placing the well an insufficient distance from an existing well.
If you check the communitized box you must attach a copy of the pooling agreement or specify the permit number for the well
under which the pooling agreement was previously submitted.
“NRC Bulletin 58” – NRC Bulletin 58 refers to the current “non-rule policy document” adopted by the Natural Resources
Commission effective 6/11/2008. The document is titled “Oil and Gas Drilling Unit and Well Spacing Requirements for
Horizontal Wells” and may be viewed on the division’s website under Publications/Notices and Examples. Select this option if
you are proposing to drill a horizontal well and identify the total drilling unit acres to be assigned to the well as provided in NRC
Bulletin 58.
If you check the Other box under the Drilling Unit section make sure to attach a copy of the exception.
You must indicate that you own or control all of the oil and gas within the proposed drilling unit before a permit can be issued.
If you do not own or control all of the oil and gas within the proposed drilling unit you must describe the basis upon which you
claim the right to drill and operate a well for oil and gas purposes.
PART III
This part is used by the division to determine if your proposed well construction will meet the rule requirements. Please be
sure to enter all information about the proposed construction so that it can be evaluated accurately.
PART IV
For all wells make sure to specify a proposed total vertical depth, deepest formation name and pool name.
For horizontal wells make sure to specify a Proposed measured length.
For Class II wells you must provide a proposed maximum allowable injection pressure and injection rate and attach all
documentation needed to evaluate your request.
PART V
The well diagram must be completed for all Class II well applications.
Proof of cement is required for all Class II wells in the form of cement tickets or a cement bond log.
PART VI
Applications that do not contain an original signature cannot be processed.
The signature must match a signature shown in Parts VI or VII of the Organizational Report.
If this application is for a Change of Operator your signature in PART VI certifies that you could not obtain this permit through
the permit transfer process ONLY because the former operator could not be located.
Important: A permit issued as a result of this application is a license to conduct an activity and does not convey any property
rights to the permittee. Consequently, the permittee is solely responsible for acquiring any and all property rights necessary
to use the permit for its stated purpose.
PART VII SURVEY
General Instructions
Use a 1"=1000' scale
Surveyor must complete the following
Clearly indicate the section township, and range on the survey, spot the well and show the footages from the lines
Use the surveyor's notes to explain deviations from a standard location such as topography and irregular sections
Operator or authorized agent must complete the following
For oil or gas wells, separately outline the boundary of both of the following:
othe leased or communitized area; AND
othe drilling unit allotment
For all Directional and Horizontal wells show the surface location AND termination point of the well.
For all Horizontal wells identify the points where each horizontal drainhole enters and departs the target zone.
For Enhanced Recovery and Saltwater Disposal wells, draw a 1/4 mile radius circle around the proposed well, spot all other wells
(plugged or unplugged) that intersect the proposed injection zone(s), and put the permit number of each well over the spot.
NOTE: Please show the entire ¼ mile radius circle around proposed Class II wells
NAD 1983 UTM Zone 16N
UTMx:
UTMy:
Enter UTM’s in meters
CERTIFICATION
I hereby certify that to the best of my knowledge and belief, the proposed location of the above described well, fixed as the result of an
instrument survey made by me in compliance with the requirements of the laws of Indiana, is truly and correctly set forth hereon.
Signature of registered Indiana land surveyor
Date signed (mm,dd,yyyy)
Address (Number and Street or PO, City, State, and ZIP code)
Telephone number
( ) -
Special PART VII Requirements
1. You should adjust the location of the center of the section on the diagram so that the entire set of information in the General
Instructions shows on a single survey plat. (Example: If a horizontal well will begin in one section but terminate in another you
should move the section center point so that portions of both sections appear on the plat)
2. This form must contain an original signature and original seal.
3. Coordinates should be based upon NAD 1983 Datum, Universal Transverse Mercator (UTM) Coordinate System, Zone 16N.
T
N
or
S
R
E or W
SURVEYORS’ NOTES:
SURVEYORS’ SEAL:
