Form BSEE-0123 Application for Permit to Drill (APD)

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Overview

0123 pg 1
0123 pg 2

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Sheet 1: 0123 pg 1

U.S. Department of the Interior

Submit original plus THREE copies,

OMB Control No. 1014-NEW

Bureau of Safety and Environmental

with ONE copy marked "Public Information."

OMB Approval Expires 04/30/2017

Enforcement (BSEE)

Application for Permit to Drill (APD)

1.

PROPOSAL TO DRILL

2. BSEE OPERATOR NO.

3. OPERATOR NAME and ADDRESS

NEW WELL

SIDETRACK

BYPASS

DEEPEN

(Submitting office)

4. WELL NAME (CURRENT)

5. SIDETRACK NO. (CURRENT)

6. BYPASS NO. (CURRENT)

7. PROPOSED START DATE

8. PLAN CONTROL NO. (NEW WELL ONLY)

9. API WELL NO. (CURRENT SIDETRACK / BYPASS) (12 DIGITS)

10.

Revision

11.

If revision, list changes:

WELL AT TOTAL DEPTH (PROPOSED)

WELL AT SURFACE

12. LEASE NO.

17. LEASE NO. and FACILITY NAME

13. AREA NAME

18. AREA NAME

14. BLOCK NO.

19. BLOCK NO.

15. LATITUDE

16. LONGITUDE

20. LATITUDE

21. LONGITUDE

( NAD 83 / NAD 27)

( NAD 83 / NAD 27)

( NAD 83 / NAD 27)

( NAD 83 / NAD 27)

LIST OF SIGNIFICANT MARKERS ANTICIPATED

22. NAME

23. TOP (MD)

24. TOP (TVD)

22. NAME

23. TOP (MD)

24. TOP (TVD)

25. LIST ALL ATTACHMENTS (Attach complete well prognosis + attachments required by 30 CFR 250.414 or 30 CFR 250.1617(c) and (d) as appropriate.)

26. CONTACT NAME

27. CONTACT TELEPHONE NO.

28. CONTACT E-MAIL ADDRESS

CERTIFICATION: I certify that information submitted is complete and accurate to the best of my knowledge. I understand that making a false statement

may subject me to criminal penalties under 18 U.S.C. 1001 (signature in # 31. below).

29. AUTHORIZING OFFICIAL (Type or print name)

30. TITLE

31. AUTHORIZING SIGNATURE

32. DATE

THIS SPACE FOR BSEE USE ONLY

APPROVED:

BY

TITLE

With Attached Conditions

Without Conditions

DATE

API WELL NO. ASSIGNED TO THIS WELL

BSEE FORM BSEE-0123 (April 2014 - Supersedes all previous versions of this form which may not be used). Page 1 of 2

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Sheet 2: 0123 pg 2

Application for Permit to Drill (APD) Information Sheet
33) Question Information Sheet
	Questions			Response	Remarks
A) Will you maintain quantities of mud and mud material (including weight materials and additives) sufficient to raise the entire system mud weight 1/2 ppg or more?				YES
				NO
				N/A
B) If hydrocarbon-based drilling fluids were used, is the drilling rig outfitted for zero discharge and will zero discharge procedures be followed?				YES
				NO
				N/A
C) If drilling the shallow casings strings riserless, will you maintain kill weight mud on the rig and monitor the wellbore with an ROV to ensure that it is not flowing?				YES
				NO
				N/A
D) If requesting a waiver of the conductor casing, have you submitted a log to BSEE District Office that is with in 500 feet of the proposed bottom hole location for the proposed surface casing point?				YES
				NO
				N/A
E) Will the proposed operation be covered by an EPA Discharge Permit? (please provide permit number in remarks for this question)				YES
				NO
				N/A
F) Will all wells in the well bay and related production equipment be shut-in when moving on to or off of an offshore platform, or from well to well on the platform? If not, please explain.				YES
				NO
				N/A
G) Is the calculated daily volume possible from an uncontrolled blowout of this well greater than the daily volume included in the worst case discharge scenario in the approved oil spill response plan?				YES
				NO
				N/A
H) Has the drilling rig been approved for the use of digital BOP testing? If yes, which version?				YES
				NO
				N/A
PAPERWORK REDUCTION ACT OF 1995 (PRA) STATEMENT: The PRA (44 U.S.C. 3501 et seq) requires us to inform you that we collect this information to obtain knowledge of equipment and procedures to be used in drilling operations. BSEE uses the information to evaluate and approve or disapprove the adequacy of the equipment and/or procedures to safely perform the proposed drilling operation. Responses are mandatory (43 U.S.C. 1334). Proprietary data are covered under 30 CFR 250.197. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB Control Number. The burden to fill out Forms BSEE-0123 + BSEE-0123S is estimated at 1 hour per response. This burden represents only the filling out of the forms, the burden for the attachments required range from 30 minutes to 2,800 hours depending on the region and the requirement. Direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance Officer, Bureau of Safety and Environmental Enforcement, 381 Elden Street, Herndon, VA 20170.
BSEE FORM BSEE-0123 (April 2014 - Supersedes all previous versions of this form which may not be used). Page 2 of 2