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Fillable Printable Form 5487

Fillable Printable Form 5487

Form 5487

Form 5487

WELL PLUGGING PLAN
Size Length Cement
Size Len
g
th Cement
Size Length Cement
F
T
Hole
Coals to protect
Well flowing?
Estimate top of cement
WELL ORIENTATION
Hole
Hole
SURFACE
Ground Level Kelly Bushing
LONG STRING
LINER / INTERMEDIATE CASING
Date received
(
month, da
y
,
y
ear
)
Date a
pp
roved
(
month
,
da
y,
y
ear
)
Date denied
(
month, da
y
,
y
ear
)
Date modified (month, day, year)
Initials
Initials
Initials
Initials
Ran
g
e
Permit number
FAX number: (317) 232-1550
Lease-Well number
Section
Count
y
Scheduled plugging date (month, day, year)
Townshi
p
FOR STATE USE ONLY
Name of operato
E-mail addressTelephone numbe
r
Fax numbe
r
Indianapolis, IN 46204
Division of Oil and Gas
Underground Source of Drinking Water
S
tate Form 54
8
7
2
(
R
/
2
-
1
4
)
/
Form No. P
2
INDIANA DEPARTMENT OF NATURAL RESOURCE
S
402 W. Washington St., Rm. 293
Telephone number: (317) 232-4055
Type of Well
Internet:http://www.in.gov/dnr/dnroil
Date (month, day, year)
Is well located in a commercially minable coal
resource area?
If so, was the entity with rights to the coal
notified?
If
y
es
,
what date notified
(
month
,
da
y,
y
ear
)
:
Contact number:
Who was notified?
Ct
EXISTING PERFORATIONS
WELL PLUGGING PLAN
Vertical Horizontal
Yes No
Yes No
Yes
No
From
To
From
To
From
To
From
To
From
To
From
To
Volume
Signature of operator or authorized agency
Cement CIBP Packer
A
FFIRMATION
I affirm under penalty of perjury that the information provided in this plan is true and correct to the best of my knowledge and belief. Furthermore, I
understand that this plan will not be valid until approved by the Division of Oil and Gas and that upon said approval, it will remain valid for a period of not
more than 180 days thereafter, unless the construction of the well has changed which also voids the plan.
Date signed (month, day, year)
PROPOSED CEMENT TYPES AND VOLUMES
Open
hole
Plugged back total depth
Total depth
Plug 2
Plug 3
Plug 4
Plug 1
Amount of proposed casing to pull
Plug number Type
PROPOSED PERFORATIONS
Comments:
Spacer
Reset Form
1
2
3
4
5
6
7
An owner or operator must submit a completed Well Plugging Report within thirty (30) days upon completion of the
plugging operations.
SPECIAL INFORMATION
For all existing wells, the owner or operator must give written notice of intent to plug by submitting this completed form
at least ten (10) days before beginning the plugging of the well. All plugging plans should be
sent directly to the Evansville field office via fax at 812-853-8648, or by email to [email protected]
.
If an emergency or urgent condition exists with a well and delay in plugging could cause harm to the environment or
threaten public health and safety, an owner or operator may begin plugging a well upon verbal approval from the
division director or a designated representative of the division director.
For dry holes, the owner or operator is required to give verbal or written notice of intent to plug a well to the oil and
gas inspector at least twelve (12) hours before beginning the plugging of the well.
If a well is located within an area of a commercially minable coal resource, the coal owner must be given at least
fifteen (15) days to review the plan.
The owner or operator may not begin the plugging of any existing well until after receipt of written approval from the
Department of the plan.
The owner or operator shall give an oil and gas inspector verbal or written notice at least forty-eight (48) hours before
the scheduled time to begin plugging operations of an existing well.
8
9
10
11
12
13
Should an owner or operator be unable to complete the plugging of a well according to this plan due to unforeseen
problems, you must receive written or verbal authorization to continue plugging operations from
the Director or Field Supervisor.
The approval of this plan, or changes to this plan during actual plugging, does not relieve the applicant from
responsibility for future remedial actions on this well as needed to prevent contamination in accordance with
IC 14-37.
All top plugs must be circulated to the surface regardless of the proposed amount of cement to be used as shown in
this plan.
You must contact the field inspector within seventy-two (72) hours after the well is plugged, to top off the well, if
necessary.
Include with this plan a copy of the most recent completion report for this well.
Keep a copy of your submitted plan for your records.
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