Form 3160-3 Application for Permit to Drill or Re-enter

Print
Form 3160 -3
(March 2012)

FORM APPROVED

OMB No. 1004-0137
Expires October 31, 2014

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT

5. Lease Serial No.
6. If Indian, Allotee or Tribe Name

APPLICATION FOR PERMIT TO DRILL OR REENTER
la. Type of work:

DRILL

lb. Type of Well:

Oil Well

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

REENTER
Gas Well

Other

Single Zone

Multiple Zone

3a. Address

8. Lease Name and Well No.
9. API Well No.

Name of Operator

2.

Reset

3b. Phone No. (include area code)

10. Field and Pool, or Exploratory

11. Sec., T. R. M. or Blk. and Survey or Area

4. Location of Well (Report location clearly and in accordance with any State requirements.*)
At surface

At proposed prod. zone
12. County or Parish

14. Distance in miles and direction from nearest town or post office*

13. State

15. Distance from proposed*

16. No. of acres in lease

17. Spacing Unit dedicated to this well

18. Distance from proposed location*

19. Proposed Depth

20. BLM/BIA Bond No. on file

location to nearest
property or lease line, ft.
(Also to nearest drig. unit line, if any)

to nearest well, drilling, completed,
applied for, on this lease, ft.

21.

Elevations (Show whether DF, KDB, RT, GL, etc.)

2.2. Approximate date work will start*

2.3. Estimated duration

24. Attachments
The following, completed in accordance with the requirements of Onshore Oil and Gas Order No.1, must be attached to this form:
1. Well plat certified by a registered surveyor.
2. A Drilling Plan.
3. A Surface Use Plan (if the location is on National Forest System Lands, the
SUPO must be filed with the appropriate Forest Service Office).

4. Bond to cover the operations unless covered by an existing bond on file (see

Item 20 above).
5. Operator certification
reguired by the
6. Such other site specific information and/or plans as may be required by the
BLM.

Name (Printed/Typed)

Date

Approved by (Signature)

Name (Printed/Typed)

Date

Title

Office

25. Signature

Title

Application approval does not warrant or certify that the applicant holds legal or equitable title to those rights in the subject lease which would entitle the applicant to
conduct operations thereon.
Conditions of approval, if any, are attached.
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.

(Continued on page 2)

*(Instructions on page 2)

INSTRUCTIONS
GENERAL: This form is designed for submitting proposals to perform certain well operations, as indicated on Federal and Indian
lands and leases for action by appropriate Federal agencies, pursuant to applicable Federal laws 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, either are shown below or will be issued by, or may be obtained from local Federal
offices.
ITEM 1: If the proposal is to redrill to the same reservoir at a different subsurface location or to a new reservoir, use this form
with appropriate notations. Consult applicable Federal regulations concerning subsequent work proposals or reports on the well.
ITEM 4: Locations on Federal or Indian land should be described in accordance with Federal requirements. Consult local Federal
offices for specific instructions.
ITEM 14: Needed only when location of well cannot readily be found by road from the land or lease description. A plat, or plats,
separate or on the reverse side, showing the roads to, and the surveyed location of, the well, and any other required information,
should be furnished when required by Federal agency offices.
ITEMS 15 AND 18: If well is to be, or has been directionally drilled, give distances for subsurface location of hole in any present
or objective productive zone.
ITEM 22: Consult applicable Federal regulations, or appropriate officials, concerning approval of the proposal before operations
are started.

NOTICES
The Privacy Act of 1974 and regulation in 43 CFR 2.48(d) provide that you be furnished the following information in connection
with information required by this application.
AUTHORITY: 30 U.S.C. 181 et seq., 25 U.S.C. 396; 43 CFR 3160
PRINCIPAL PURPOSES: The information will be used to: (1) process and evaluate your application for a permit to drill a new
oil, gas, or service well or to reenter a plugged and abandoned well; and (2) document, for administrative use, information for
the management, disposal and use of National Resource Lands and resources including (a) analyzing your proposal to discover
and extract the Federal or Indian resources encountered; (b) reviewing procedures and equipment and the projected impact on the land
involved; and (c) evaluating the effects of the proposed operation on the surface and subsurface water and other environmental impacts.
ROUTINE USE: Information from the record and/or the record will be transferred to appropriate Federal, State, and local or
foreign agencies, when relevant to civil, criminal or regulatory investigations or prosecution, in connection with congressional
inquiries and for regulatory responsibilities.
EFFECT OF NOT PROVIDING INFORMATION: Filing of this application and disclosure of the information is mandatory only
if you elect to initiate a drilling or reentry operation on an oil and gas lease.
The Paperwork Reduction Act of 1995 requires us to inform you that:
The BLM collects this information to allow evaluation of the technical, safety, and environmental factors involved with drilling
for oil and/or gas on Federal and Indian oil and gas leases. This information will be used to analyze and approve applications.
Response to this request is mandatory only if the operator elects to initiate drilling or reentry operations on an oil and gas lease.
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 Street, N.W., Mail Stop 401 LS, Washington,
D.C. 20240.
______________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________

(Form 3160-3, page 2)