Record of Written Consent

Transcription

1

2 8000-PM-OOGM0001bU Rev. 5/2017 COMMONWEALTH OF PENNSYLVANIA Record of Notification / Written Consent DEPARTMENT OF ENVIRONMENTAL PROTECTION OFFICE OF OIL AND GAS MANAGEMENT of Applicant PERMIT APPLICATION TO DRILL AND OPERATE AN UNCONVENTIONAL WELL Record of Notification US Well No. (API No.) I hereby certify that, for all interested parties identified on the plat of this application for which written consent or an Affidavit of Non-Delivery of Certified Mail has not been uploaded, copies of the well plat have been sent via certified mail and I have received a return receipt verifying delivery. of Person Authorized to Submit Application (Print or Type) Name of Signer: BRANDEN WEIMER List the following: surface landowner; surface landowners and water purveyors with water supplies within 3,000 feet; municipality where the well will be drilled; adjacent municipality; municipalities within 3,000 feet of the vertical well bore; gas storage operator if within 3,000 feet. Mark the boxes, X, which show the parties interests. Use additional forms if you need more space. You are required to notify each of these parties. Notification: below name indicates the party s acknowledgement of receipt of the well location plat and serves as proof of notification Trever L. Bookhardt Brent G. & Wanda Y. Broadwater Title: Surface Landowner Permit Team Lead Gas Storage Operator Surface Landowners & Water Purveyors with water supplies <3000' Municipalities Notification Note the means and attach proof. Certified Mail Dates Sent Return Receipt 141 West Bend Road East Millsboro, PA X 11/15/17 11/20/ Cemetery Road East Millsboro, PA X 11/15/17 11/18/17 Address Affidavit Date Written Consent Russell W. Jr. & Charlene D. Franks Walter B. & Phyllis M. Palmer Nellie P. Foster 372 Heistersburg Road East Millsboro, PA X 11/15/17 X 575 Palmer Lane East Millsboro, PA X 11/15/17 11/21/ N. Lewis Run Road Apt 103 Pittsburgh, PA X 11/21/17 X Record of Written Consent Written Consent: below indicates the party s approval of the well location, or indicates written consent and waives the 15-day objection period where applicable. Print and Sign Name: Date Print and Sign Name: Date Print and Sign Name: Date Check applicable box Surface Owner Water Well within 500 feet Building within 500 feet

3

4

5

6

7

8

9 8000-PM-OOGM0001bU Rev. 5/2017 COMMONWEALTH OF PENNSYLVANIA Record of Notification / Written Consent DEPARTMENT OF ENVIRONMENTAL PROTECTION OFFICE OF OIL AND GAS MANAGEMENT of Applicant PERMIT APPLICATION TO DRILL AND OPERATE AN UNCONVENTIONAL WELL Record of Notification US Well No. (API No.) I hereby certify that, for all interested parties identified on the plat of this application for which written consent or an Affidavit of Non-Delivery of Certified Mail has not been uploaded, copies of the well plat have been sent via certified mail and I have received a return receipt verifying delivery. of Person Authorized to Submit Application (Print or Type) Name of Signer: BRANDEN WEIMER List the following: surface landowner; surface landowners and water purveyors with water supplies within 3,000 feet; municipality where the well will be drilled; adjacent municipality; municipalities within 3,000 feet of the vertical well bore; gas storage operator if within 3,000 feet. Mark the boxes, X, which show the parties interests. Use additional forms if you need more space. You are required to notify each of these parties. Notification: below name indicates the party s acknowledgement of receipt of the well location plat and serves as proof of notification Luzerne Township German Township Redstone Township Brownsville Township Borough of Brownsville Title: Surface Landowner Permit Team Lead Gas Storage Operator Surface Landowners & Water Purveyors with water supplies <3000' Municipalities Notification Note the means and attach proof. Certified Mail Dates Sent Return Receipt 415 Hopewell Road Brownsville, PA X 11/15/17 11/17/17 2 Long Street McClellandtown, PA X 11/15/17 11/17/ Twin Hills Road Grindstone, PA X 11/15/17 11/17/ Brown Street Brownsville, PA X 11/15/17 11/24/ Second Street Brownsville, PA X 11/15/17 11/17/17 Record of Written Consent Written Consent: below indicates the party s approval of the well location, or indicates written consent and waives the 15-day objection period where applicable. Print and Sign Name: Date Print and Sign Name: Date Print and Sign Name: Date Check applicable box Address Affidavit Date Written Consent Surface Owner Water Well within 500 feet Building within 500 feet

10 8000-PM-OOGM0001bU Rev. 5/2017 COMMONWEALTH OF PENNSYLVANIA Record of Notification / Written Consent DEPARTMENT OF ENVIRONMENTAL PROTECTION OFFICE OF OIL AND GAS MANAGEMENT of Applicant PERMIT APPLICATION TO DRILL AND OPERATE AN UNCONVENTIONAL WELL Record of Notification US Well No. (API No.) I hereby certify that, for all interested parties identified on the plat of this application for which written consent or an Affidavit of Non-Delivery of Certified Mail has not been uploaded, copies of the well plat have been sent via certified mail and I have received a return receipt verifying delivery. of Person Authorized to Submit Application (Print or Type) Name of Signer: BRANDEN WEIMER List the following: surface landowner; surface landowners and water purveyors with water supplies within 3,000 feet; municipality where the well will be drilled; adjacent municipality; municipalities within 3,000 feet of the vertical well bore; gas storage operator if within 3,000 feet. Mark the boxes, X, which show the parties interests. Use additional forms if you need more space. You are required to notify each of these parties. Notification: below name indicates the party s acknowledgement of receipt of the well location plat and serves as proof of notification Cumberland Township Jefferson Township Borough of Rices Landing East Bethlehem Township Centerville Borough Title: Surface Landowner Permit Team Lead Gas Storage Operator Surface Landowners & Water Purveyors with water supplies <3000' Municipalities Notification Note the means and attach proof. Certified Mail Dates Sent Return Receipt 100 Municipal Road Carmichaels, PA X 11/15/17 11/17/ Goslin Road Rices Landing, PA X 11/15/17 11/21/ Main Street PO Box 185 Rices Landing, PA X 11/15/17 11/20/17 36 Water Street PO Box 687 Fredericktown, PA X 11/15/17 11/18/ East End Road Brownsville, PA X 11/15/17 11/17/17 Record of Written Consent Written Consent: below indicates the party s approval of the well location, or indicates written consent and waives the 15-day objection period where applicable. Print and Sign Name: Date Print and Sign Name: Date Print and Sign Name: Date Check applicable box Address Affidavit Date Written Consent Surface Owner Water Well within 500 feet Building within 500 feet