Form 139 Form 139 Application to Drill or Reenter

Form 139 (Rev) (March 2015)			FORM APPROVED OMB No. [] Expires XX/XX/XXXX
UNITED STATES DEPARTMENT OF THE INTERIOR OSAGE AGENCY APPLICATION FOR PERMIT TO DRILL OR REENTER
			5. Lease Serial No.
			6. If Indian, Allotee or Tribe Name
1a. Type of work: DRILL REENTER 1b. Type of Well: Oil Well Gas Well Other 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*) 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 office*			12. Country 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. BIA Bond No. on file
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 25 C.F.R. Part 226, must be attached to this form:
1. Well plate certified by registered surveyor 2. A Drilling Plan.		3. Bond to cover the operations unless covered by an existing bond on file (see Item 20 above). 4. Operator certification 5. Such other site specific information and/or plans as may be required by the BIA.
25. Signature	Name (Printed/Typed)		Date
Title
Approved by (Signature)	Name (Printed/Typed)		Date
Title	Office
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 conduction 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, fictitious or fraudulent statements or representations as to any matter within its jurisdiction.
(Continued on page 2)		*(Instructions on page 2)

INSTRUCTIONS

GENERAL: This form is designed for submitting proposals to perform certain well operations, as indicated on Indian lands and leases for action by appropriate Federal agencies, pursuant to applicable Federal laws and regulations.

ITEM 1: 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 well.

ITEM 4: Locations on Indian land should be described in accordance with Federal requirements. Consult local Federal offices for specific 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 well, and any other required information, should be furnished when required by Federal agency offices.

ITEM 15 AND 18: If well is to be, or has been directionally drilled, give distances for subsurface location of hold in any present or objective productive zone.

ITEM 22: Consult applicable Federal regulations, or appropriate officials, concerning approval of the proposal before operations are started.

NOTICES

The Privacy Act of 1974 and regulation in 25 C.F.R. 226.34(b) provide that you be furnished the following information in connection with information required by this application.

AUTHORITY: 25 C.F.R. Part 226, 200 DM 1, 209 DM 8, 230 DM 1, 3 IAM 4.1 and Muscogee Area Addendum 9901 to 3 IAM 4

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 well 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 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 will 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 BIA/Osage Agency collects this information to allow 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 BIA/Osage Agency 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 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: Information Collection Clearance Officer – Indian Affairs, 1849 C Street, N.W., Mail Stop 3642, Washington, DC 20240.