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2. APPLICANT NAME*
3. APPLICANT REPRESENTATIVE*
5. APPLICANT EMAIL CONTACT*
6. APPLICANT IS A:*
   -- Select One --CORPORATIONPARTNERSHIPINDIVIDUALOTHER
8. APPLICANT MAILING ADDRESS*
10. APPLICANT MAILING ADDRESS*
    CITY, STATE, ZIP CODE
12. APPLICANT PHONE CONTACT*
13. DEVELOPMENT DETAILS:*
    -- Select One --OIL WELLPIPELINE LOCATIONVALVE NEW - OR REPAIRBUILDING PAD OR ROAD

    WHAT IS THE PROJECT?
15. ADDITIONAL PROJECT DETAILS:*
    -- Select One --NEW DRILLRECOMPLETIONAMENDEDRE-ENTERRE-CLASSFIELD TRANSFER
17. API NUMBER:
18. RRC PERMIT#
19. ABOVE GROUND PIPELINE VALVES
    -- Select One --YESNO
21. WELL NAME
22. WELL #
23. ENTRANCE ROAD NAME
25. LEASE AND OR WELL NAME
27. POTENTIAL DEVELOPMENT SITE PROPERTY ADDRESS*
    YOU WILL NEED TO PROVIDE PROOF OF CURRENT ADDRESS. CONTACT BRAZOS COUNTY 911 DISTRICT (979) 779-0911TO RECEIVE ADDRESS INFORMATION.
29. POTENTIAL DEVELOPMENT SITE PROPERTY ADDRESS*
    CITY, STATE, ZIP CODE
31. LEGAL DESCRIPTION
33. PROPERTY ACERAGE
34. PROPERTY ID:
36. DEVELOPMENT INFORMATION:

    1. OIL WELL
    2. PIPELINE
    3. VALVE SITE
37. STRUCTURAL DEVELOPMENT ACTIVITY

    1. NEW DRILL
    2. RECOMPLETION
    3. AMENDED
    4. RE- ENTER
    5. RE - CLASS
    6. FIELD TRANSFER
38. OTHER DEVELOPMENT ACTIVITIES

    1. CLEARING
    2. FILLING
    3. MINING
    4. DRILLING
    5. GRADING
    6. EXCAVATION
    7. WATERCOURSE ALTERATION
    8. DRAINAGE IMPROVEMENTS
    9. OTHER
39. MATERIAL BROUGHT IN?*

    1. FILL BROUGHT IN
    2. FILL TAKEN OUT
    3. NO CHANGE IN FILL
41. PROPERTY OWNER INFORMATION
43. NAME
44. PHONE
45. EMAIL
47. REGULATORY ANALYST
49. NAME
50. PHONE
51. EMAIL
53. RIGHT OF WAY MANAGER
55. NAME
56. PHONE
57. EMAIL
59. SURVEYOR
61. NAME
62. PHONE
63. EMAIL
65. ENGINEER
67. NAME
68. PHONE
69. EMAIL
71. FIELD SUPERVISOR
73. NAME
74. PHONE
75. EMAIL
77. CONSTRUCTION MANAGER
79. NAME
80. PHONE
81. EMAIL
83. DRILLING COMPANY
85. NAME
86. PHONE
87. EMAIL
89. EMERGENCY CONTACTS
    TWO REPRESENTATIVES WITH SUPERVISORY AUTHORITY OVER ALL OIL AND GAS OPERATION SITE ACTIVITIES THAT CAN BE REACHED TWENTY-FOUR (24) HOURS A DAY.
91. NAME*
92. PHONE*
94. NAME*
95. PHONE*
Leave This Blank:


97. 1. Receive an email copy of this form.
98. Email address

    This field is not part of the form submission.

99. Submit

* indicates a required field