Form 3160-3
(June 2019)
OMB No. 1004-0137
Expires: October 31, 2021
5. Lease Serial No.
6. If Indian, Allotee or Tribe Name
1a. Type of work:
1b. Type of Well:
Oil Well Gas Well Other
1c. Type of Completion:
Hydraulic Fracturing
Single Zone
Multiple Zone
7. If Unit or CA Agreement, Name and No.
8. Lease Name and Well No.
2. Name of Operator
9. API Well No.
3a. Address
3b. Phone No. (include area code)
10. Field and Pool, or Exploratory
4. Location of Well (Report location clearly and in accordance with any State requirements.*)
At surface
At proposed prod. zone
11. Sec., T. R. M. or Blk. and Survey or Area
14. Distance in miles and direction from nearest town or post ofce*
12. County or Parish 13. State
15. Distance from proposed*
location to nearest
property or lease line, ft.
(Also to nearest drig. unit line, if any)
16. No of acres in lease 17. Spacing Unit dedicated to this well
18. Distance from proposed location*
to nearest well, drilling, completed,
applied for, on this lease, ft.
19. Proposed Depth
20. BLM/BIA Bond No. in le
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 certied 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 led with the appropriate Forest Service Ofce).
4. Bond to cover the operations unless covered by an existing bond on le (see
Item 20 above).
5. Operator certication.
6. Such other site specic information and/or plans as may be requested by the
25. Signature
Name (Printed/Typed)
Approved by (Signature)
Name (Printed/Typed)
Title Ofce
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, ctitious or fraudulent statements or representations as to any matter within its jurisdiction.
(Continued on page 2) *(Instructions on page 2)
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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 ofces.
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
ITEM 4: Locations on Federal or Indian land should be described in accordance with Federal requirements. Consult local
Federal ofces for specic 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 ofces.
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 ofcials, 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, when
applicable by 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.
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 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 Conection Clearance Officer (WO-630), 1849 C Street, N.W., Mail Stop 401
LS, Washington, D.C. 20240.
(Form 3160-3, page 2)