Form 3260-3
(April 2019)
OMB NO. 1004-0132
Expires: February 29, 2020
6. Lease Serial No.
The Bureau of Land Management (BLM) requires this form or other BLM approved forms to be prepared and
filed in triplicate with requisite attachments. The BLM must approve this permit prior to any lease operations.
7. Surface Manager: BLM FS
8. Unit Agreement Name
1a. Well Type: Production Injection Heat Exchange Observation Other 9. Well No. 10. Permit No.
1b. Well Status: 11. Field or Area
2. Name of Lessee/Operator 12. Sec., T., R., B. & M.
3. Address of Lessee/Operator 13. County
4. Location of Well or Facility
14. State
5. Type of Work
Change Plans Convert to Injection Pull or Alter Casing
Site and Road Construction Fracture Test Multiple Complete
Construct New Production Facilities Shoot or Acidize Abandon
Alter Existing Production Facilities Repair Well Other
15. Describe Proposed Operations (Use this space for well activities only. See instructions for current well conditions on page 2.)
16. Describe Proposed Operations (Use this space for activities other than well work.)
17. I hereby certify that the foregoing is true and correct.
Signed______________________________________________________ Title _______________________________________________ Date __________________________
(This space for Federal use)
Approved by _________________________________________________ Title _______________________________________________ Date _________________________
Conditions of Approval, if any:
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)
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This form must be used for applications for well work, road, site and facilities construction and other miscellaneous activities performed on Federally
leased lands which are related to operations performed under an approved Plan of Operation.
Item 1b: Show the current status for existing wells: I=injecting, F=flowing, P=pumping, HE=heat exchange, SI=shut-in, WS=water supply,
OB=observation, O=other (explain).
Item 15: The latest well conditions (hole size, casing, cement, perforations, producing and injecting zones, etc.) along with all proposed
additions/changes must be shown. When completing this section, list existing well program first, followed by the proposed program, and separate by a
sufficient space to clearly distinguish the two programs. Current well conditions may be either listed in this section or may be shown by attaching a copy
of the latest completion report on the subject well.
Item 16: Attach all pertinent engineering plans and specifications.
Completed Operations: Thirty days after completion of all operations other than construction activities, approved under this permit, a completion report
must be submitted in duplicate, to the BLM. The completion report must include a copy of the approved Geothermal Sundry Notice with an attached
report detailing all important activities performed and the completion and abandonment procedures undertaken. Copies of all records of the operations
must accompany the report if not previously submitted.
The Privacy Act of 1974 and the regulations in 43 CFR 2.48(d) require that you be furnished with the following information:
AUTHORITY: 30 U.S.C. 1001-1028; 43 CFR Part 3200.
PRINCIPAL PURPOSE: The BLM uses this information to evaluate the technical, safety and environmental factors involved with geothermal resources
on Federal geothermal leases.
ROUTINE USES: (1) The adjudication of the form. (2) Documentation for public information in support of notations made on land status, records for the
management, disposal; and use of public lands and resources. (3) Transfer to appropriate Federal agencies when concurrence is required prior to granting
a right in public lands or resources. (4) 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.
EFFECT OF NOT PROVIDING INFORMATON: Disclosure of the information is required to process the application. If all the information is not
provided, the application may be rejected.
The Paperwork Reduction Act of 1995 requires us to inform you that:
The BLM collects this information to evaluate your proposed and/or completed subsequent well operations on Federal geothermal leases.
The BLM will use this information to report subsequent operations once work is completed, and, when you request it, to approve subsequent operations.
Response to this request is required to receive or retain a benefit.
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 (1004-0132), Bureau Information Collection Clearance Officer (WO-630),
1849 C Street, N.W., Washington D.C. 20240.
(Form 3260-3, page 2)