Title 40 CFR Part 191
Waste Isolation Pilot Plant
DEL Attachment 2
U.S. Bureau of Land Management Forms
1. TYPC OI W0.K
APPLICATION FOR PERMIT TO DRILL OR DEEPEN
DRILL 0 DEEPEN 0
I I I
6. D UDuII. ALLDIN 0. ~1.c
7. uau As-.m "An.
.- . IMSTRUCTIOWS
. . . . . - ._ . -. -. . - ._ .
CENERAL: TMa fom is desigmdfa -pmpm.ls b- ccr(.in .ell ogrr
tbna, u bdieaed. a all types of lamb 6 kuca h- ' te .etion 4 &be? a
Puled or a Stae acemcy. a bot4 pnt8suat to .ppLiuble Fedrnl ad/- State hwa .nd
rrgll.Licmr Any nerr*urg aPed.l ie*ctioms concemiog tke use of thi. form d the
mtmber of copies to he anbdnd, putidaly wifh regmd to 1 6 .m, or reeicmal
drea an4 ymoticn. either are shown helm or rill be issd by, or =my lw &bed
hau, Ihe local PNknl d o r SUte office.
ITEM 1 : If the proposal it to rrddll to the b.mc mser.oir st a diff-t subsurface loce
tim or to a new mmoir. use tbb fmm with nppmpsime aotr(i- Consult .ppliclblc
State ot Fedenl re@atioms mncnning sllboequent work propods or reports on the well.
ITEM 4: I[ thm uc so applicable Stlte rupi-ents, locations 00 F-1 or Indim
1-d should be dessibed in acconlmrce with Fedenl -ests.
w Fedenl office for speciGc insMctious.
Cousnlt local State
ITEM (4: Needed d y when location of well c8nnot readily be follnd by mad from the
Imd or 1ea.e description A plat. or plats, sep.rate or on this m e side. sh0-g the
mads to, .nd the sumeyed loc8tiom of. the well. and any other requirdidormation. shoold
h fmnisbed ahen mmired by Federal or St8te agency office..
ITEMS IS ANO 18: lf well )s to be. 01 h8s been directiopllly drilled. eve distances for
subsdace location of hole in pny psat or objective pmcktnion zone.
ITEM e. Consalt applicable F-1 Or'Stnte recdations. or app-eate
crming approval of the pmpooal before opmtions are stuted
Tbe Privacy Act of 1974 nnd the rrgrrlatioo in 43 CFR 2.4Nd) provide that you be furnished
the following idrnr.tiom ill Urnnectiou mth iUfOIm8tiOn by this npplicatioo.
AUTHORITY: 30 U.SC 181 et t4.. 25 U:Sc. 3%: 43 CFP. Ppt 3160.
PRlNClPAL m E 'Ilc inforpatio. is 10 k Iwd to pmcea nd cvrluu y ~ sppliurioa r for permit
10 drill Or deep I8 oil 01 8s Well.
ROUTINE USES: (1) The dysis of the applic.nt's -ml to discover and extract
the Federal or Indiau Rsows encountered. (2) The mi- of pocedures aud equip
-t and the projected impact on the land involved (3) Ibe evaluation of the effects of
pmposed oper8tion on mrfacc md subsurface amter Md 0th- .enri.olmental impacts.
(4)(5) Momstion from the record .nd/or the record Will be umofnrcd to 8ppropriote
Federal. %ate, local or foreign a-cies. ahen relevarat to civil, enminal or re@utory
investigations or pmse=3xtiour, as well as routine regul.torg responsibility.
EFFECT OF NOT PROVIDING INFORMATION Filisg of tkir appliulion aid disclossre of the
imfomatios ir ma.d.ior)r oaly if the opentor elmu 10 imili.tc drillimgopenliom 00 am oil amd gS lux.
BURDEN HOURS STATEMENT
Public reporting burden forthh form isenimued to amage Mninutcspermporsc. includingthe time for
reviewing ijsnxtiots, gmhing md dtainhg data. and compleung and rmxiag thc form. hrect
commcnurryrdithe burdrnotimucormyother~ofthirformtoU.S. Ikpmmentofthclnterior.
Bureau of tnd Managemat. (Nlmutc) Buruu c*Maa Offkr. (WO-771). I849 C SvCn. N.W..
Washington. D.C. 20240. ad tk Mi of Mmymcnt and Budget, Paperwork Redunion Rojen
(10044136). Wahingtoa D.C. Mso3.
me Paperaork Reduction Act of 1980 (44 U.S.C. 3501 et scq) -re% us to inform YOU
This informmtion is being collected to allow evaluation of the technical. safrty, md cn-
d-ental facton involved With drilling for oil nud/or gas on Feden1 nnd Indian oil
md gas leases.
Tbir id-atioa rill be used to aalyze .nd approve applications.
Ruposrc Y) Ibis rrqmut h maadalmry Omly if lbc Openlor clccts to imiIi.1~ drilling operalions 01 1. oil
1.d gas luu.
*US. CPOs 1991-573-016/26066
(July 1992) SUBMIT IN DZRUUTE.
DEPARTMENT OF THE INTERIOR
r- WELL COMPLETION OR RECOMPLETION REPORT AND LOG*
1. TYPE OF WELL
X L 0 ?:x8 0 0". 0 0lh.l
I I I I I
*(See In-ciianr and Spaen Icr Additional Data on Rwm Side)
OMB NO 10014137
Lprer: Februan 3, I995
:. I.*..Sr. "..,*)l.rI"" 1°C. .'"'.L "0
rille 1s U.S.C. Section 1001. maker it a cnme for any person knowingly and 0rillIulIy to make 10 any department or agency of the
United Sriler any false. fic:itiouL 01 fraudulent OtPxement5 or repre~enfstlon~ as to any matter wUm it5 junsdiction.
37. SUMMARY OF POROUS ZONES: (Show all irnporlanl zones of porosily end conlents thereof; cored inlerval~; and .I!
drill-stern. testa. including depth inletval lerled. cushion used, lime lool open. flowing and shul-in pressures.
DESCRIPTION. CONTENTS, ETC.
GEOLOGIC MARKERS .’
TYPE OF SUBMISSION
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
SUNDRY NOTICES AND REPORTS ON WELLS
Do not use this form for proposals to drill or to deepen or reentry to a different resewoir.
Use “APPLICATION FOR PERMIT-” for such proposals
SUBMIT IN TRIPLICATE
- “DC Of Wcll 1
TYPE OF ACTION
Budp &mu No IUY413S
7. ir ulvi or CA. Ag-t ~er~gnum
This form is designed for submiuing proposals to prform Cmain well o p-
arions. and rcports of such operations when completed. as indicated. on
?ral and Indian lands pursuant to applicable Federal law and regula-
3, and, if approved or accepted by any State, on all lands in sucb State.
pursuant to applicable State law and regulations. Any necessay special in-
SPEC1 FIC INSTRUCTIONS
sm~ctlons cowmng the we of thls form and the number of copes to k
sub&. pa~~cularly with regard to local Ma, Or regiod
and ptacttces, uther arc shown klow or will be issued by, or may 1
tamed from. the local Federal and/or State office.
frem &If there arc no applicable State requirements. locations on Federal zones, or other zones with present significant fluid contents not scaled off
or Indian land should be described in accordance with Federal miranem. I bv ccmenl or Mhcnviw. d& (too and &om) and method of ~iacmmt
Consult local State or Federal offtce for specific instructions.
&cement plugs: mud or oker %enat placed below. benvcm Bod above
plugs: amount, size. mcmod of parting of any casing. lina or tubing pulled
hem 13--Proposals to abandon a well and subsequent report5 of abandon- and the dcpth to top of any left in the hole; method of dosing top of well;
ment should include such spccial information as is rquircd by Id Feder- and date well site conditioned for final inqxeion looking to approval of
al ador State officcs. In &tion, such pmposais and rcpom sbould include the abandonment.
rcam~~ for the abandonment; data on any former or present productive
The Privacy AR of 1974 and the regulation in 43 CFR 2.48(d) provide chat you k furnished the
following information in connection with information required by this application.
AIJWIORITY: 30 U.S.C. 181 d. seq., 351 et. sq., 25 U.S.C. ct. sq.; 43 CFR 3160.
PRINCIPAL PURPOSE - The information is to k used to evaluate. when appropriate. appmve
applications. and rcpon completion of secondary well opcracions, on a Federal or Indian Icaw.
(1) Evaluate the equipment and praedure5 used during the proposed or completed subsequent
(2) Request and gnnt approval to perform those actions covered by 43 CFR 3162.3-Z(2).
(3) Analyze fururc applications to drill or modify opcnoonS in light of data obtaid and nurhais
(4)(5) Infodon from the record andor the record will k transferred to appropriate Federal,
State, local or foreign agencies. when relevant to civil, criminal or rcgulamy invcstipiaons
EFFECT OF NOT PROVIDING INFORMATION - Filing of this notie and repon and disclosure
of the information is mandatory o m an oil or gas well is drilled.
The Paperwork Reduction Act of 1980 (44 U.S.C. 3501, ct. seq.) requires us to inform yw that:
This information is king collected in order to cvaluav proposed andlor completed subsequent well
operations on Federal or Indian oil and gas leaxs.
This information will be used to rcpon subsequent operations once worl; is cornpletd and when
requested. IO obmn approval for subsequent opcruions not previously authorized.
Rapon% to this quest k maKktory for the @tic rypa of mivma spaiW in 43 CFR Pan 3160.
BURDEN HOURS STATEMENT
reviewing imtrunionr. gathering and maintaining data and completing and reviewing the form. Dirm
commcnlsregudingthe burden~timateoranyotherupnoft~formto US. Lkpvtmcntofthe Interior.
Bureau of Land Mpnyment. (Altcnute) Bureau Clearance OK=, (WO-771). 18 and C Succlr. N.W.,
Wzhington. D.C. 20240. and the Ofkc of Management and Budget. Paperwork Redunion Project
(ILW4-0135). Washingion. D.C. 10503.
DEPARTMENT OF THE INTERIOR
PROSPECTING APPLICATION AND PI
2. Give legel description of land requested (See Gcnernl
Insrrurtron /m ~?ss~s~~ncc on land description ij nredcdl
Total acre; I Rental Submitted S
I 1. What mineral are you applying fox
OMB NO. 1002-0030
Emires: May 31. 1990
3. Legal description of land included in permit
APPLICANT DOES NOT FILL IN rtiis SPACE
Total acres 1 Rental retained S
&Are you the sole panY in interest? n Yes No IZee Sperilic lnsrrucrion No. 51
Are you B citizen of the United States? Yes 0 No I b. Are you over the age of majority? u Yes 0 No
7n. Is application made for a-corporation or other legal entity? 0 Yes 0 No fSee Jpeci/ic Insrrurrrons No. 70 and 761
b. Has a statement of qualification been filed? 0 Yes 0 No (I/ “yes.” giue /ile nurnberl
8. Have you enclosed a filing fee
of5 CI Yes
9. Have you enclosed the first year‘s advance rental computed at the rate of
I ‘CERTIFY mat my Interests. direct or indirect, m leases, pemxts. and spp~ic~txons therefor. do not exceed the maxmum permitted by law
or regulation, and that the statements made herein are tme, complete. and correct to the best of my knowledge and bekcf and are madem
(Signature of Applicant) (Signature of Applicant)
Title 18 U.S.C. Section 1001. makes it a crime for any person knowingly and willfully to make to any department or agency of the
Uniied States eny false, fiCtitimS or fraudulent Statements 01 representations as to any matter within its jurisdiction.
A permit for the lands in Item 3. above is hereb issued under the
0 Mineral Leasing Act, 30 U.S.C. 181 et seq. 6 Acquired Lands
Leasing Act, 30U.S.C. 351 efseq. 43CFR3511 pf seq. andissubject
to all regulations in force and to the terns and conditions set forth on
Effecuve date of pernit BY
Thrs permit is issued for a period of-years
DO NOT WRITE BELOW THfS LINE
the reverse side hereof.
This permit, to the extent applicable, is subject to standard or special
stipulations. Stipuktions if any, are attached.
THE UNITED STATES OF AMERICA
Sec. 1. Prospecting. Permittee shall diligently prospect the lands by
core drilling or other acceptable methods. Permittee shall notify the
authorized officerin which thepermitlandsaresituaiedofhis plansfor
prospecting prior to commencement of prospect work.
Sec. 2. Operating regulations. (a) Permittee shall comply with all
regulations of the Secretary of the Interior: and, as to the lands
described herein under his jurisdiction, to the regulations and ordersof
the Secretary of Agriculture.
(b) Permittee shall comply with the provisions of the operating
regulations of the Bureau of Land Management (43 CFR 3570) and all
orders issued pursuant thereto. Copies of the operating regulations
may be obtained from the authorized officer.
(c) Permittee shall not prospect lands under administrative juris.
dinion of the Forest Service without prior notice to and consent of that
Service to a pian for prospecting.
(d) Permittee shall allow inspection of the premises and operations
by duly authorized representatives of the Departments of the Interior.
Agriculture. orotheragencyadministering thelandsandshall provide
lands under authority of the United States.
Sec. 3. Multiple use. (a) Valid existing rights acquired prior hereto on
the lands described herein will not be adversely affected hereby.
(bl The granting of this permit will not preclude the issuance of
other permits, leases, or other development of the same lands.
(cl The permitted lands shall be subject, at all times. to any other
lawful uses by the United States. its lessees, permittees. licensees, and
assigns. but such use shall notmateriallyinterferewith thepermittee's
(d) The Government reserves theright tosell or otherwisedisposeof
the surface of the permitted lands under existing law or laws hereafter
enacted. insofar as such disposal will not materially interfere with the
rights of the permittee.
(el The permittee shall afford all facilities for inspection of the
prospecting work on behalf of the Secretary of the Interior or head of
agencyadministering the landsandtomakeareport,on demand, ofall
matters pertaining to the character, progress. and results ofsuch work.
(0 The permittee shall observe such conditions as to the use and
occupancy of the surface of the lands as provided by law, in case any of
said lands shall have been or may be entered or patented with a
reservation of mineral deposits to the United States.
Sec.4. Removolofdeposits. Permitteeshall removefromthelandsonly
such deposits as may be necessary toexpenmental work or toestablish
a record of all mineral mined.
Sec 5. Rental. Permittee must pay an annual rental of cents per
acre. or fraction thereof. but not less than 620 per year. The annual
rental payment shall be made on or before the anniversary date of the
Sec. 6. Extensionofpermit. (a) This permitmay besubject toextension
under applicable regulation upon approval of the authorized officer of
the Bureau of Land Management and upon the showing of entitlement
(b) Application for extension of this permit. where authorized by
law or regulation, must be filed. in duplicate. in the proper BLM office
within the period beginning 90 days prior to the date of expiration of
this permit. Unless such an application is filed within the tine
specified, this permit will expire without notice to the permittee.
jec. 7. Reward for discouery. Permittee may apply for a preference
right lease if he shall have discovered valuable deposits of minerals
covered by this permit within the permit area and within the period of
this permit as issued. The showing required to be made in the
preference-right lease application is set forth in the Lppropriate
regulation. In addition, the applicant for a sodium, potassium. or
sulphur preferenceright lease must show that the lands applied for art
chiefly valuable. See appropriate regulations. Also see appropnatt
regulation for limitation on acreage holdings.
Sec.8. Equalopportunityclave. This permitissubjecttothepror.=ion.
of Executive Order No. 11246 of Sept. 24.1965, as amended. which seu
forth the nondiscrimination clauses- A copy of this order may be
obtained from the signing officer.
Sec. 9. Assignments. All assignments or transfers of this permit or of
any interest therein. whether by direct assignment. operating agree-
ment sublease. working interest. royalty interest. or otherwise. must be
filed with the Bureau of Land Management for approval in accordance
with the provisionsofthe appropriate regulation and will takeeffect as
ofthefirst day of themonth following approval thereof. or. if transferee
sorequests,asofthefirstdayofthemonth duringwhichsuch approval
Sec. 10. Relinquishment of permit. Permittee may relinquish chi?
permit, in whole or part, by filing in the proper BLM office a written
relinquishment.in triplicate, whichshall beeffectiveasofthedateit LS
filed. subject to the continued obligation of permittee and his surety to
make payment of all accrued rentals and royalties: and. to provide for
the preservation of any mines or productive works. or permanent
improvements on the pennit land as required by the applicable
regulations and terms of this permit.
Sec. 11. Termination or cancellation. (a1 This permit shall terminate
automatically upon failure of the permittee to pay the rental on or
before the anniversary date thereof, except that if the time for payment
falls upcn any day in which the appropriate land office to receive
paymentisnotopen,paymentreceived on thenext official workingday
shall be deemed to be timely.
(b) Thispermit may becancelledinaccordancewith the regulations
upon failure by permittee toexerciseduediligenceintheproseci"?of
the prospecting work or for violation of any terms and COT IS
hereof. or any of the pertinent regulations.
jec. 12. Protection of surface. natural resources. and improvements.
Thepermitteeagreestotakesuchreasonablestepsas may beneededto
prevent operations on the permitted lands from unnecessarily:
:11 causing orcontributingtosoilerosionordamaging crops.including
forage, and timber growth thereon or on Federal or nan-Federal lands
.n the vicinity; (2) polluting air and water: (3) damaging improve.
nents owned by the United States or other-panies; or (4) desuoyinp.
iamaging or removing fossils. historic or prehistoriciuins. arartifacts:
3nd upon any partial or total relinquishment or the cancellation or
!xpiration of this permit, or at any other time prior thereto when
Fquired and to the extent deemed necessary by the lessor to fill any
iits. ditches and other excavations, remove or cover all debris. and so
:ar as reasanablypossible.restorethesurfaceofthepermitied land and
iccess roads to their former condition. including the removal of
itructures as and if required. The lessor may prescribe the steps to he
aken and restoration to be made with respect to the permitted lands
mdimprovements thereon whetheror not owned by the United States.
jec. 13. AntiQuIties and obiects of historic value. When American
intiquities or other object, of historic or scientific interest includinp
nut not limited to historic or prehistoric ruins. fossils or artifacts are
liscovered in the performances of this permit. the item(s) or condi-
ionW will beleftintactandimmediately broughtto theattention ofthe
:ontracting officer or his authorired representative.
jet. 14. Sodium deposits in oil shale areas. If this application is for
:odium minerals in the oil shale area described in P.L.0. 4522.
ieptember 24. 1968. a prospecting permit will be issued only in those
ireas where it is believed likely that, if sodium deposits are found&ey
"ill OCCUT in discrete beds where development of the sodium dr 's
vouldnotadverselyaffecttheoilshalevalvesofthelands. Anys 3
irospecting permits or preference-right leases that may issue on tnese
Nil shale lands will be restricted to those beds valuable for sodium
which the Secretan of the Interior or his delegate determines to be
workable without removal of significant amounrs of organic matter
Ind without significant damage to oil shale beds.
*U.S. GOVERNMENT PRINTING OFFICE (PW-57r.87'