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Fill and Sign the Becomes a Part of Lease Contract Form

Fill and Sign the Becomes a Part of Lease Contract Form

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APPLICATION FOR VARIANCE FROM MINIMUM CONSTRUCTION STANDARDS Water Wells/Test Holes/Monitoring Wells/Geotechnical Borings Oklahoma Water Resources Board Planning & Management Division 3800 Classen Blvd. Oklahoma City, Oklahoma 73118 Telephone: (405) 530-8800 Fax: (405) 530-8900 Official Use Only FILING FEE: $50.00 - Groundwater wells, Heat Exchange $150.00 - Monitoring wells & geotechnical borings Variance Request Number: VR 20____ - MUST ACCOMPANY APPLICATION 1. NAME AND ADDRESS Print applicants name and mailing address, with zip code. If available include FAX number and E-Mail address. If a corporation, use name and business address of the corporation. Applicants Name Contact Name Address Telephone ( ) City FAX Number ( ) State/ZIP Code E-Mail 2. LOCATION OF WELLS a. State the county in which site is located type and number of wells for which a variance is being requested. County OCC Case # b. Legal location of wells, test holes monitoring wells or borings which are the subject of this application. Descriptions should be to the nearest 10-acre tract of land or GPS location. If more space is needed for legal descriptions, list on a separate sheet of paper. Physical address of wells: Number of well (s) Type of well Quarter, Quarter, Quarter (10 acre tract) Section Township Range Or GPS - Latitude & Longitude Qtr. Qtr. N Qtr. S Lat. Qtr. Long. Qtr. N Qtr. S Lat. Qtr. ECM WIM EIM Long. Qtr. N Qtr. S Lat. 3. ECM WIM EIM ECM WIM EIM Long. ADDITIONAL INFORMATION Provide the following information with this form for proper evaluation of the variance request. a b c d Detailed lithologic description of the site(s) geology through which wells are completed, including any water bearing zones; Schematic drawing showing diameter, depth and the manner in which wells are constructed; Map showing location of all wells, test holes or geotechnical borings on site; Detailed description of the type of variance being requested and technical justification for alternative method of construction or plugging. Name of Applicant (Print or Type) Date Signature of Applicant Date Well Variance Application June 1, 2013 www.owrb.ok.gov

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