Form 3160-3 APPLICATION FOR PERMIT TO DRILL OR REENTER

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Form 3160-3
(June 2015)

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

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
APPLICATION FOR PERMIT TO DRILL OR REENTER
1a. Type of work:

DRILL

1b. Type of Well:

Oil Well

1c. Type of Completion:

Hydraulic Fracturing

5. Lease Serial No.
6. If Indian, Allotee or Tribe Name
7. If Unit or CA Agreement, Name and No.

REENTER
Gas Well

Other
Single Zone

8. Lease Name and Well No.

Multiple Zone

2. Name of Operator
3a. Address

9. API Well No.
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*
location to nearest
property or lease line, ft.
(Also to nearest drig. unit line, if any)
18. Distance from proposed location*
to nearest well, drilling, completed,
applied for, on this lease, ft.

16. No of acres in lease

17. Spacing Unit dedicated to this well

19. Proposed Depth

20. BLM/BIA Bond No. in file

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

22. Approximate date work will start*

23. Estimated duration

24. Attachments
The following, completed in accordance with the requirements of Onshore Oil and Gas Order No. 1, and the Hydraulic Fracturing rule per 43 CFR 3162.3-3
(as applicable)
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.
6. Such other site specific information and/or plans as may be requested 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 I: 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 wen, 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 directionany 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.
ITEM 24: 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 wells. Information may also be obtained from state or tribal regulatory agencies and from local BLM offices.

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 wen 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 win 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 conects this information to anow 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 agencysponsored 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 Conection Clearance Officer (WO-630), 1849 C Street, N.W., Mail Stop 401
LS, Washington, D.C. 20240.
(Form 3160-3, page 2)