Form BSEE-0124 Application for Permit to Modify (APM)

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Overview

0124 pg 1
0124 pg 2

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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. 1014-0026

Bureau of Safety and Environmental

OMB Approval Expires 05/31/2017

Enforcement (BSEE)

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, 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.

Completion

Workover:

Enhance Production

Initial Completion

Change Tubing

Acidize

Reperforation

Casing Pressure Repair

Artifical Lift

Change Zone

Wash/Desand Well

Modify Perforations

Abandonment of Well Bore:

Jet Well

Utility

Permanent Abandonment

Hydraulic Fracturing

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 250.465; 250.513(a) through (d); 250.514(d); 250.516(a); 250.517(d)(8); 250.517(d)(9)(i); 250.613(a) through (d); 250.614(d); 250.616(a); 250.616(f)(4); 250.617(d); 250.617(h)(1); 250.617(h)(2)(i); 250.1706(a); 250.1706(f)(4); 250.1707(d); 250.1709; 250.1712(a) through (g); 250.1721(a); 250.1722(a); 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 BSEE USE ONLY

APPROVED BY:

TITLE

DATE

BSEE Form BSEE-0124 (May 2014 - Supersedes all previous versions of this form which may not be used.) Page 1 of 2

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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 approval 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
CERTIFICATION: I certify that the information submitted is complete and accurate to the best of my knowledge. I understand that making a false statement may subject me to criminal penalties under 18 U.S.C. 1001.
Name and Title: _________________________________________ Date: ____________________
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. BSEE 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 reviewing the instructions, completing and filling out this form only is estimated to average 1 hour per response. The burden for the attachments required in the form range from 10 minutes to 1.5 hours depending on the requirement. Direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance Officer, Bureau of Safety and Environmental Enforcement, 381 Elden Street, Herndon, VA 20170.
BSEE Form BSEE-0124 (May 2014- Supersedes all previous versions of this form which may not be used.) Page 2 of 2