Form 139A Form 139A Notice and Reports on Wells

Form 139(A) (March 2015)					FORM APPROVED OMB No. [] Expires XX/XX/XXXX
UNITED STATES DEPARTMENT OF THE INTERIOR OSAGE AGENCY NOTICES AND REPORTS ON WELLS Do not use this form for proposals to drill or to re-enter an abandoned well.
					5. Lease Serial No.
					6. If Indian, Allotee or Tribe Name
1 Type of well: □ Oil Well □ Gas Well □ Other:					7. If Unit or CA Agreement, Name and No.
					8. Well Name and No.
2. Name of Operator					9. API Well No.
3a. Address	3b. Phone No. (include area code)				10. Field and Pool, or Exploratory Area
4. Location of Well (Footage, Sec., T., R., M., or Survey Description)					11. Country or Parish, State
12. CHECK THE APPROPRIATE BOX(ES) TO INDICATE NATURE OF NOTICE, REPORT, OR OTHER DATA
TYPE OF SUBMISSION	TYPE OF ACTION
□ Notice of Intent □ Subsequent Report □ Final Abandonment Notice	□ Acidized □ Deepen □ Production (Start/Resume) □ Water Shut-off □ Alter Casing □ Facture 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 measure 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 BIA/Osage Agency. 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 208 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 USE
Approved by	Title				Date
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 entitle the applicant to conduct operations thereon.				Office:
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 conduction 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.
(Instructions on page 2)

INSTRUCTIONS

GENERAL: This form is designed for submitting proposals to perform certain well operations and reports of such operations when completed as indicated on Indian lands 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 4: Locations on Indian land should be described in accordance with Federal requirements. Consult local Federal offices for specific instructions.

ITEM 13: Proposals to abandon a well and subsequent reports of abandonment should include such special information as is required by the local Federal office. In addition, such proposals and reports should include reasons for the abandonment; data on any former or present productive zones or other zones with present significant fluid contents not sealed off by cement or otherwise; depths (top and bottom) and method of placement of cement plugs; mud or other material placed below, between and above plugs; amount, size, method of parting of any casing, liner or tubing pulled and the depth to the top of any tubing left in the hole; method of closing top of well and date well site conditioned for final inspection looking for approval of abandonment.

NOTICES

The Privacy Act of 1974 and regulation in 25 C.F.R. 226.34(b) provide that you be furnished the following information in connection with information required by this application.

AUTHORITY: 25 C.F.R. Part 226, 200 DM 1, 209 DM 8, 230 DM 1, 3 IAM 4.1 and Muscogee Area Addendum 9901 to 3 IAM 4

PRINCIPAL PURPOSES: The information will be 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 granting approvals; (c) reporting the beginning or resumption of production; and (d) analyzing future applications to drill or modify operations in light of data obtained and methods used.

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 for well operations.

The Paperwork Reduction Act of 1995 requires us to inform you that:

The BIA/Osage Agency 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 BIA/Osage Agency 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 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: Information Collection Clearance Officer – Indian Affairs, 1849 C Street, N.W., Mail Stop 3642, Washington, DC 20240.