OHIO DEPARTMENT OF NATURAL RESOURCES DOGRM Engineering Group Affix PE Seal DIVISION OF OIL & GAS RESOURCES MANAGEMENT (330) 308-0007 2045 Morse Road, F-2 • Columbus, OH 43229-6693 An up-to-date Horizontal Well Site Modification Summary is required to be on-site during all construction. Modifications Horizontal Well Site Modification Summary Rev. 09/18 must be recorded below and uploaded by the well operator within 24 hours. Well Site Information Professional Engineer Identification Number: PE Name: Permit Number: or Pre-rule OH License Number: Site Name: Phone: Work: Mobile: Owner Name: Email: Company Name: Site Location County: Township: Street Address: / OH / Section/Lot Number: City / State / Zip: MATERIAL MODIFICATION MODIFIED PERSONNEL MODIFICATION PLAN OR MATERIAL COMPLETING DATE DATE DATE NUMBER DATE MODIFICATION DESCRIPTION REPORT PAGES MODIFICATION? DETERMINATION SUBMITTED APPROVED COMMENCED
OHIO DEPARTMENT OF NATURAL RESOURCES DIVISION OF OIL & GAS RESOURCES MANAGEMENT 2045 Morse Road, F-2 • Columbus, OH 43229-6693 DOGRM Engineering Group (330) 308-0007 Affix PE Seal Horizontal Well Site Modification Summary Rev. 09/18 An up-to-date Horizontal Well Site Modification Summary is required to be on-site during all construction. Modifications must be recorded below and uploaded by the well operator within 24 hours. Well Site Information Identification Number: Permit Number: or Pre-rule Site Name: Owner Name: Site Location County: Township: Section/Lot Number: Professional Engineer PE Name: OH License Number: Phone: Work: Mobile: Email: Company Name: Street Address: City / State / Zip: / OH / MODIFICATION MODIFICATION DESCRIPTION MODIFIED PLAN OR REPORT PAGES MATERIAL MODIFICATION? PERSONNEL COMPLETING DETERMINATION MATERIAL MODIFICATION DATE SUBMITTED DATE APPROVED DATE COMMENCED NUMBER DATE
HWS_ModSummary.docx