Well Site Inspection Report

North Carolina Department of Environment and Natural Resources Division of Energy, Mineral, and Land Resources Energy Section - Oil and Gas Program

Form 29 Rev 03/2015

Oil & Gas Program Use Only Date:

1612 Mail Service Center, Raleigh, NC 27699-1612 Phone: (919) 707-9220 Fax: (919) 715-8801 Email: [email protected]

Received by: Document ID:

Well Site Inspection Report

15A NCAC 05H .2201

Permittee Name:

Indicate the Date and Type of Inspection:

Company Name:

Date: Type: Daily Inspection

Address: City:

State:

Monthly Inspection

Zip:

*Other:

Phone:

* Reason for Other Inspection:

Fax: Email: API Number:

Nearest Town/City:

Lease/Well Name: Well Number: Well Site Phase:

Well Site Ingress/ Egress Location:

County: Pre-Construction

Construction

Drilling

Production

P/A

Reclamation

1. Facilities and Equipment located at the Well Site: Facility/Equipment Tank

Condition:

Description of Needed Repairs:

Repairs Needed

Tank

Tank Tank Tank Tank Tank Tank Tank Tank

Tank Tank

Tank

Page

API Number:

Form 29 - Well Site Inspection Report

2. Wellhead:

Permittee Name:

3. Tank(s): Casing String:

Pressure (psi):

Tank ID:

Filter(s):

Relief Valve:

Hatch Lids:

Lightning Arrestors:

Conductor: Surface: Intermediate: Production:

4. Spill or Release:

Yes

Type:

No

If a spill or release is detected, the permittee is required to file a Form 26 - Spill and Release Report pursuant to 15A NCAC 05H .2005.

Area:

Volume/Quantity:

Description of Initial Actions: 5. Additional Comments or Notes for Inspection:

This form must be signed by the permittee or an authorized agent of the permittee. Print Name:

Title:

Signature:

Date:

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