Form 0124 Application for Permit to Modify (APM)

---

Overview

0124 pg 1
0124 pg 2

---

Sheet 1: 0124 pg 1

U.S. Department of the Interior

Submit original plus THREE copies,with ONE copy marked "Public Information."

OMB Control No. 1010-0141

Bureau of Ocean Energy Management,

OMB Approval Expires xx/xx/xxxx

Regulation and Enforcement (BOEMRE)

Application for Permit to Modify (APM)

1. WELL NAME (CURRENT)

2. SIDETRACK NO. (CURRENT)

3. BYPASS NO. (CURRENT)

4. OPERATOR NAME and ADDRESS

(Submitting office)

5. API WELL NO. (12 digits)

6. START DATE (Proposed)

7. ESTIMATED DURATION (DAYS)

8.

9.

If revision, please list changes:

Revision

WELL AT TOTAL DEPTH

WELL AT SURFACE

10. LEASE NO.

13. LEASE NO.

11. AREA NAME

14. AREA NAME

12. BLOCK NO.

15. BLOCK NO.

Proposed or Completed Work

16. PROPOSED OR COMPLETED WORK (Describe in Section 17)

PLEASE SELECT ONLY ONE PRIMARY TYPE IN BOLD AND AS MANY SECONDARY TYPES AS NECESSARY.

Enhance Production

Workover:

Completion:

Acidize

Change Tubing

Initial Completion

Artifical Lift

Casing Pressure Repair

Reperforation

Wash/Desand Well

Change Zone

Jet Well

Abandonment of Well Bore:

Modify Perforations

Utility

Permanent Abandonment

Initial Injection Well

Temporary Abandonment

Information:

Additional Fluids for Injection

Plugback to Sidetrack/Bypass

Surface Location Plat

Other Operations

Site Clearance

Change Well Name

Describe Operation(s)

17. BRIEFLY DESCRIBE PROPOSED OPERATIONS (Attach prognosis):

18. LIST ALL ATTACHMENTS (Attach complete well prognosis and attachments required by 30 CFR 250.513(a) through (d); 250.613(a) through (d); 250.1712(a) through (g); 250.1721(a) through (h); 250.1722(a) through (d); or 250.1743(a).

19. Rig Name or Primary Unit (e.g., Wireline Unit, Coil Tubing, Snubbing Unit, etc.)

20. The greater of SITP or MASP (psi):

21. Type of Safety Valve (SV): ___ SCSSV ___SSCSV ___ N/A

22. SV Depth BML (ft): ______

23.

Rig BOP (Rams)

24.

Rig BOP (Annular)

Size:

Working Pressure

Test Pressure

Working Pressure

Test Pressure

(inches)

(psi)

(psi)

(psi)

(psi)

________

___________

Low/High: ________

_________

Low/High: _________

25. Coiled Tubing BOP:

26.

Snubbing Unit BOP:

27.

Wireline Lubricator:

Working Pressure

BOP Test Pressure

Working Pressure

Test Pressure

Working Pressure

Test Pressure

(psi)

(psi)

(psi)

(psi)

(psi)

(psi)

____________

Low/High: __________

____________

Low/High: _________

Low/High: _________

________

28. CONTACT NAME:

29. CONTACT TELEPHONE NO.:

30. CONTACT E-MAIL ADDRESS:

31. AUTHORIZING OFFICIAL (Type or print name)

32. TITLE

33. AUTHORIZING SIGNATURE

34. DATE

THIS SPACE FOR BOEMRE USE ONLY

APPROVED BY:

TITLE

DATE

BOEMRE Form 0124 (Mo/Year- Supersedes all previous versions of this form which may not be used.) Page 1 of 2

---

Sheet 2: 0124 pg 2

Application for Permit to Modify (APM) Information Sheet
35) Question Information
	Questions			Response		Remarks
a) Is H2S present in the well? If yes, then comment on the inclusion of a Contingency Plan for this operation.				YES
				NO
				N/A
b) Is this proposed operation the only lease holding activity for the subject lease? If yes, then comment.				YES
				NO
				N/A
c) Will all wells in the well bay and related production equipment be shut-in when moving on to or off of an offshore platform, or from well to well on the platform? If not, please explain.				YES
				NO
				N/A
d) If sands are to be commingled for this completion, has aproval been obtained?				YES
				NO
				N/A
e) Will the completed interval be within 500 feet of a block line? If yes, then comment.				YES
				NO
				N/A
f) For permanent abandonment, will casings be cut 15 feet below the mudline? If no, then comment.				YES
				NO
				N/A
PAPERWORK REDUCTION ACT OF 1995 (PRA) STATEMENT: The PRA (44 U.S.C. 3501 et. seq.) requires us to inform you that we collect this information to obtain knowledge of equipment and procedures to be used in drilling operations. BOEMRE uses the information to evaluate and approve or disapprove the adequacy of the equipment and/or procedures to safely perform the proposed drilling operation. Responses are mandatory (43 U.S.C. 1334). Proprietary data are covered under 30 CFR 250.197. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB Control Number. Public reporting burden for BOEMRE Form 0124 is estimated to average 17 hours per response. This includes 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 the Information Collection Clearance Officer, Mail Stop 5438, Bureau of Ocean Energy Management, Regulation and Enforcement, 1849 C Street, NW, Washington, DC 20240.
BOEMRE Form 0124 (Mo/Year - Supersedes all previous versions of this form which may not be used.) Page 2 of 2