Form 3160-5 Sundry Notices and Reports on Wells

Print
Form 3160-5
(May 2015)
(March
2012)

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT

5. Lease Serial No.

SUNDRY NOTICES AND REPORTS ON WELLS
Do not use this form for proposals to drill or to re-enter an
abandoned well. Use Form 3160-3 (APD) for such proposals.
1. Type of Well
Gas Well

FORM APPROVED
OMB No. 1004-0137
2018
Expires: January
October 31, 2014

6. If Indian, Allottee or Tribe Name

7. If Unit of CA/Agreement, Name and/or No.

SUBMIT IN TRIPLICATE – Other instructions on page 2.
Oil Well

Reset

8. Well Name and No.

Other

2. Name of Operator

9. API Well No.

3a. Address

3b. Phone No. (include area code)

4. Location of Well (Footage, Sec., T.,R.,M., or Survey Description)

10. Field and Pool or Exploratory Area
11. County or Parish, State

12. CHECK THE APPROPRIATE BOX(ES) TO INDICATE NATURE OF NOTICE, REPORT OR OTHER DATA
TYPE OF SUBMISSION
Notice of Intent
Subsequent Report
Final Abandonment Notice

TYPE OF ACTION
Acidize

Deepen

Production (Start/Resume)

Water Shut-Off

Alter Casing

Hydraulic
Fracturing
Fracture Treat

Reclamation

Well Integrity

Casing Repair

New Construction

Recomplete

Other _____________________

Change Plans

Plug and Abandon

Temporarily Abandon

________________________

Convert to Injection

Plug Back

Water Disposal

________________________

13. Describe Proposed or Completed Operation: Clearly state all pertinent details, including estimated starting date of any proposed work and approximate duration thereof. If
the proposal is to deepen directionally or recomplete horizontally, give subsurface locations and measured and true vertical depths of all pertinent markers and zones.
Attach the Bond under which the work will be performed or provide the Bond No. on file with BLM/BIA. Required subsequent reports must be filed within 30 days
following completion of the involved operations. If the operation results in a multiple completion or recompletion in a new interval, a Form 3160-4 must be filed once
testing has been completed. Final Abandonment Notices must be filed only after all requirements, including reclamation, have been completed and the operator has
determined that the site is ready for final inspection.)

14. I hereby certify that the foregoing is true and correct. Name (Printed/Typed)
Title
Signature

Date

THIS SPACE FOR FEDERAL OR STATE OFFICE USE
Approved by
Title
Conditions of approval, if any, are attached. Approval of this notice does not warrant or certify
that the applicant holds legal or equitable title to those rights in the subject lease which would
Office
entitle the applicant to conduct operations thereon.

Date

Title 18 U.S.C. Section 1001 and Title 43 U.S.C. Section 1212, make it a crime for any person knowingly and willfully to make to any department or agency of the United States any false,
fictitious or fraudulent statements or representations as to any matter within its jurisdiction.
(Instructions on page 2)

GENERAL INSTRUCTIONS

This form is designed for submitting proposals to perform certain well operations and reports of such operations when completed as
indicated on Federal and Indian lands pursuant to applicable Federal law and regulations. Any necessary special instructions concerning the
use of this form and the number of copies to be submitted, particularly with regard to local area or regional procedures and practices, are
either shown below, will be issued by or may be obtained from the local Federal office.

SPECIFIC INSTRUCTIONS

Item 4 - Locations on Federal or Indian land should be described in accordance with Federal requirements. Consult the local Federal office
for specific instructions.
Item
toto
abandon
a well
and
subsequent
reports
of of
abandonment
should
include
such
special
information
as as
is required
byby
the local
Item13:
13 Proposals
- Proposals
abandon
a well
and
subsequent
reports
abandonment
should
include
such
special
information
is required
Federal
Inoffice.
addition,
proposals
and reportsand
should
include
reasons
forreasons
the abandonment;
data on any
former
or present
productive
the localoffice.
Federal
In such
addition,
such proposals
reports
should
include
for the abandonment;
data
on any
former or
zones
or productive
other zoneszones
with present
contents
not sealed
by cement
or otherwise;
depthsor
(top
and bottom)
and(top
method
present
or othersignificant
zones withfluid
present
significant
fluid off
contents
not sealed
off by cement
otherwise;
depths
and of
otherbetween
material and
placed
below,
between
and size,
abovemethod
plugs; of
amount,
method
of liner
of placement
cement
plugs;
mud or
bottom) and
placement
of method
cement plugs;
mud orof
other
material
placed
below,
above
plugs;
amount,
partingsize,
of any
casing,
parting
any casing,
or to
tubing
pulled
andtubing
the depth
to the
the hole;
top ofmethod
any tubing
left in top
the of
hole;
of well
closing
of well and
or
tubingofpulled
and theliner
depth
the top
of any
left in
of closing
wellmethod
and date
sitetop
conditioned
fordate
final
of the abandonment.
well site conditioned
final inspection
looking for approval
inspection
looking forfor
approval
of the abandonment.
If the proposal
will involve hydraulic fracturing operations, you must comply with 43
CFR 3162.3-3, including providing information about the protection of usable water. Operators should provide the best available information
about all formations containing water and their depths. This information
could include data and interpretation of resistivity logs run on nearby
NOTICES
The Privacy
Act ofmay
1974also
andbe
theobtained
regulation
in state
43 CFR
2.48(d)
provide agencies
that you and
be furnished
theBLM
following
information in connection with
wells.
Information
from
or tribal
regulatory
from local
offices.
information required by this application.
NOTICES
AUTHORITY: 30 U.S.C. 181 et seq., 351 et seq., 25 U.S.C. 396; 43 CFR 3160.
PRINCIPAL PURPOSE: The information is used to: (1) Evaluate, when appropriate, approve applications, and report completion of
subsequent well operations, on a Federal or Indian lease; and (2) document for administrative use, information for the management,
disposal and use of National Resource lands and resources, such as: (a) evaluating the equipment and procedures to be used during a
proposed subsequent well operation and reviewing the completed well operations for compliance with the approved plan; (b) requesting
and grantingapproval to perform those actions covered by 43 CFR 3162.3-2, 3162.3-3, and 3162.3-4; (c) reporting the beginning or
resumption of production, as required by 43 CFR 3162.4-1(c)and (d) analyzing future applications to drill or modify operations in light
of data obtained and methods used.
ROUTINE USES: Information from the record and/or the record will be transferred to appropriate Federal, State, local or foreign
agencies, when relevant to civil, criminal or regulatory investigations or prosecutions in connection with congressional inquiries or to
consumer reporting agencies to facilitate collection of debts owed the Government.
EFFECT OF NOT PROVIDING THE INFORMATION: Filing of this notice and report and disclosure of the information is mandatory
for those subsequent well operations specified in 43 CFR 3162.3-2, 3162.3-3, 3162.3-4.
The Paperwork Reduction Act of 1995 requires us to inform you that:
The BLM collects this information to evaluate proposed and/or completed subsequent well operations on Federal or Indian oil and gas
leases.
Response to this request is mandatory.
The BLM would like you to know that you do not have to respond to this or any other Federal agency-sponsored information collection
unless it displays a currently valid OMB control number.
BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average 8 hours per response, including the
time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the
burden estimate or any other aspect of this form to U.S. Department of the Interior, Bureau of Land Management (1004-0137), Bureau
Information Collection Clearance Officer (WO-630), 1849 C St., N.W., Mail Stop 401 LS, Washington, D.C. 20240

(Form 3160-5, page 2)