Form 3160-5 Sundry Notices and Reports on Wells

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

UNITED STATES

Form 3160-5
(June 2015)

DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT

5. Lease Serial No.

SUNDRY NOTICES AND REPORTS ON WELLS
Do not use this form for proposals to drill or to re-enter an
abandoned well. Use Form 3160-3 (APD) for such proposals.

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

SUBMIT IN TRIPLICATE - Other instructions on page 2
1. Type of Well
Oil Well

Gas Well

6. If Indian, Allottee or Tribe Name

8. Well Name and No.

Other

9. API Well No.

2. Name of Operator
3b. Phone No. (include area code)

3a. Address

10. Field and Pool or Exploratory Area
11. Country or Parish, State

4. Location of Well (Footage, Sec., T.,R.,M., or Survey Description)

12. CHECK THE APPROPRIATE BOX(ES) TO INDICATE NATURE OF NOTICE, REPORT OR OTHER DATA
TYPE OF SUBMISSION
Notice of Intent
Subsequent Report
Final Abandonment Notice

TYPE OF ACTION
Acidize

Deepen

Production (Start/Resume)

Water Shut-Off

Alter Casing

Hydraulic Fracturing

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 measured and true vertical depths of all pertinent markers and zones. Attach
the Bond under which the work will be perfonned or provide the Bond No. on file with BLM/BIA. 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 3160-4 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 detennined 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

THE SPACE FOR FEDERAL OR STATE OFICE USE
Approved by
Title
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.

Date

Office

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)

GENERAL INSTRUCTIONS
This form is designed for submitting proposals to perform certain well operations and reports of such operations when completed as
indicated on Federal and Indian lands pursuant to applicable Federal law 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, are
either shown below, will be issued by or may be obtained from the local Federal office.

SPECIFIC INSTRUCTIONS
Item 4 - Locations on Federal or Indian land should be described in accordance with Federal requirements. Consult the local Federal office
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 the abandonment. 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 the 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., 351 et seq., 25 U.S.C. 396; 43 CFR 3160.
PRINCIPAL PURPOSE: The information is 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 approval to perform those actions covered by 43 CFR 3162.3-2, 3162.3-3, and 3162.3-4; (c) reporting the beginning or
resumption of production, as required by 43 CFR 3162.4-1(c)and (d) analyzing future applications to drill or modify operations in light
of data obtained and methods used.
ROUTINE USES: Information from the record and/or the record will be transferred to appropriate Federal, State, local or foreign
agencies, when relevant to civil, criminal or regulatory investigations or prosecutions in connection with congressional inquiries or to
consumer reporting agencies to facilitate collection of debts owed the Government.
EFFECT OF NOT PROVIDING THE INFORMATION: Filing of this notice and report and disclosure of the information is mandatory
for those subsequent well operations specified in 43 CFR 3162.3-2, 3162.3-3, 3162.3-4.
The Paperwork Reduction Act of 1995 requires us to inform you that:
The BLM collects this information to evaluate proposed and/or completed subsequent well operations on Federal or Indian oil and gas
leases.
Response to this request is mandatory.
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 ofthis form to U.S. Department ofthe Interior, Bureau ofLand Management (1004-0137), Bureau
Information Collection Clearance Officer (WO-630), 1849 C St., N.W., Mail Stop 401 LS, Washington, D.C. 20240

(Form 3160-5, page 2)