OHIO DEPARTMENT OF NATURAL RESOURCES DIVISION OF OIL & GAS RESOURCES MANAGEMENT ODNR Internal Use Only 2045 Morse Road, F-2 • Columbus, OH 43229-6693 Owner #: Orphan Well Landowner Pass-through Payment Plugging Application I&O Case #: Rev. 01/17 County: Applicant Name: Mailing Address: Civil Township: Section: Lot: City / State / Zip: / / Fraction Qtr Township: Phone: Tract/Allot: Email: Is the well or production facility within an urbanized area as Well Name: defined by ORC 1509.01 (Y)? API Number: Date of Last Production: Emergency Numbers Closest to well site. Amount of Oil: BBL Fire: Medical: Amount of Gas: MCF Means of Ingress and Egress Total Depth to be Plugged: FT Road: Additional Information This application shall be accompanied by a copy of a proposed contract to plug the well prepared by a contractor regularly engaged in the business of plugging oil and gas wells. The proposed contract shall require the contractor to furnish all of the materials, equipment, work, and labor necessary to plug the well properly and shall specify the price for doing the work, including a credit for the equipment appurtenant to the well that was forfeited to the state as a result of Section (C)(2) of Ohio Revised Code 1509.071. PRINT NAME PRINT TITLE SIGNATURE OF OWNER/AUTHORIZED AGENT DATE SIGNED If signed by authorized agent, a certified copy of appointment of agent must be attached or on file at the division.
OHIO DEPARTMENT OF NATURAL RESOURCES DIVISION OF OIL & GAS RESOURCES MANAGEMENT 2045 Morse Road, F-2 • Columbus, OH 43229-6693 ODNR Internal Use Only Orphan Well Landowner Pass-through Payment Plugging Application Rev. 01/17 Owner #: I&O Case #: Applicant Name: Mailing Address: City / State / Zip: / / Phone: Email: Well Name: API Number: County: Civil Township: Section: Lot: Fraction Qtr Township: Tract/Allot: Is the well or production facility within an urbanized area as defined by ORC 1509.01 (Y)? Date of Last Production: Amount of Oil: BBL Amount of Gas: MCF Total Depth to be Plugged: FT Emergency Numbers Closest to well site. Fire: Medical: Means of Ingress and Egress Road: Additional Information This application shall be accompanied by a copy of a proposed contract to plug the well prepared by a contractor regularly engaged in the business of plugging oil and gas wells. The proposed contract shall require the contractor to furnish all of the materials, equipment, work, and labor necessary to plug the well properly and shall specify the price for doing the work, including a credit for the equipment appurtenant to the well that was forfeited to the state as a result of Section (C)(2) of Ohio Revised Code 1509.071. PRINT NAME PRINT TITLE SIGNATURE OF OWNER/AUTHORIZED AGENT DATE SIGNED If signed by authorized agent, a certified copy of appointment of agent must be attached or on file at the division.