BSEE-0123S Supplemental APD Information Sheet

U.S. Department of the Interior						OMB Control No. 1014-0025
Bureau of Safety and Environmental						OMB Approval Expires 04-30-2020
Enforcement (BSEE)
	Supplemental APD Information Sheet (Casing Design)
1) Operator Name:				2) Well Name (Proposed):			ST:	BP:
3) Bottom Hole Lease:				4) Surface Lease:
5) API Number:				6)Type of Well:		Exploratory	Development
7) H2S:		Absent		8) H2S Activation Plan Depth (TVD) (ft):
9) Rig Name:				10) SubSea BOP:		Yes	No
11) Water Depth (ft):			12) RKB Height (ft):			13) Mineral Code:
14) Drive Pipe Size (in):			15) Drive Pipe Depth (ft):			16) Anchors	Yes	No
17) Well Design Information
Interval Number:			Type:			Name:
Section Number	Casing Size (in)	Casing Weight (#/ft)	Casing Grade	Burst Rating (psi)		Collapse Rating (psi)	Depth (ft) MD TVD	Pore Pressure (ppg)
GENERAL INFORMATION			PREVENTER INFORMATION			TEST INFORMATION
Hole Size (in)			Type			Annular Test (psi)
Mud Weight (ppg)			Size (in)			BOP/Diverter Test (psi)
Mud Type Code			Wellhead Rating (psi)			Mud Test Weight (ppg)
Frac Gradient (ppg)			Annular Rating (psi)			Casing/Liner Test (psi)
Liner Top Depth (ft)			BOP/Diverter Rating (psi)			Formation Test (ppg)
Cement Volume (ft3)
Interval Number:			Type:			Name:
Section Number	Casing Size (in)	Casing Weight (#/ft)	Casing Grade	Burst Rating (psi)		Collapse Rating (psi)	Depth (ft) MD TVD	Pore Pressure (ppg)
GENERAL INFORMATION			PREVENTER INFORMATION			TEST INFORMATION
Hole Size (in)			Type			Annular Test (psi)
Mud Weight (ppg)			Size (in)			BOP/Diverter Test (psi)
Mud Type Code			Wellhead Rating (psi)			Mud Test Weight (ppg)
Frac Gradient (ppg)			Annular Rating (psi)			Casing/Liner Test (psi)
Liner Top Depth (ft)			BOP/Diverter Rating (psi)			Formation Test (ppg)
Cement Volume (ft3)
Interval Number:			Type:			Name:
Section Number	Casing Size (in)	Casing Weight (#/ft)	Casing Grade	Burst Rating (psi)		Collapse Rating (psi)	Depth (ft) MD TVD	Pore Pressure (ppg)
GENERAL INFORMATION			PREVENTER INFORMATION			TEST INFORMATION
Hole Size (in)			Type			Annular Test (psi)
Mud Weight (ppg)			Size (in)			BOP/Diverter Test (psi)
Mud Type Code			Wellhead Rating (psi)			Mud Test Weight (ppg)
Frac Gradient (ppg)			Annular Rating (psi)			Casing/Liner Test (psi)
Liner Top Depth (ft)			BOP/Diverter Rating (psi)			Formation Test (ppg)
Cement Volume (ft3)
* NOTE*	For additional casing/liner intervals, please submit an additional Form BSEE-0123S.
CERTIFICATION: I certify that the 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.
Name and Title: ____________________________________________ Date: ____________________
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. 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, 45600 Woodland Road, Sterling, VA 20166.
BSEE Form BSEE-0123S (April 2017-Supersedes all previous versions of this form which may not be used.) Page 1 of 1