IR-9F Abandoned Well Inspection for Contractors.pdf

IR-9F Well Class: _____ Rev: 09/2022

State of West Virginia Department of Environmental Protection

Office of Oil and Gas

Abandoned Well Inspection Form for Contractors in Federal Funding Projects

I. Well Identification

API Number: Assigned Number:

Well Operator:

Farm/Landowner: Well Number:

II. Well Location

Quad: District: County:

Latitude: Longitude:

III. Impacts to public health or safety

1. Does this well appear to be an immediate threat to human health or safety, i.e., sinkhole, explosion hazard, noxious gas/chemicals, unstable equipment? If yes, explain. NO ☐ YES ☐

Note: An affirmative response to Question 1 results in an automatic Class 1 designation

2. Does this well appear to be a potential (i.e., non-imminent) threat to human health or safety. If yes, explain. NO ☐ YES ☐

Note: An affirmative response to this question results in an automatic Class 2 designation

IV. Impacts to the environment

3. Is this well leaking fluids (i.e., oil and/or saltwater) at the surface? Is leakage minor or significant? Check all that apply. If yes, explain, and include an estimate on the volume of fluids leaking.

NO ☐ OIL ☐ MINOR ☐ SIGNIFICANT ☐

SALTWATER ☐ MINOR ☐ SIGNIFICANT ☐

Note: An affirmative response for significant leakage of any fluids for Question 3 results in an automatic Class 1 designation. Minor leakage results in a Class 2 designation.

4. Is there evidence of contaminated soil around the wellhead? NO ☐ YES ☐

If yes, explain and estimate the size of the impacted area.

5. If yes to question 3, has fluid leakage escaped the well location? NO ☐ YES ☐

If yes, explain.

Note: An affirmative response to Question 5results in an automatic Class 1 designation

6. Is there evidence of groundwater contamination within 1,000 ft of well. NO ☐ YES ☐

If yes, explain.

Note: An affirmative response to Question 6 will result in an automatic Class 1 designation

7. Is this well leaking gas? Is leakage minor or significant? Check all that apply. If yes, explain detection methodology and include gas detector make and model, if used. Note that any well exhibiting leaking methane is subject to contract methane quantification requirements.

NO ☐ METHANE ☐ MINOR ☐ SIGNIFICANT ☐

H2S ☐

Note: An affirmative response for significant leakage of methane or any H2S for Question 7 results in an automatic Class 1 designation. Minor leakage of methane results in a Class 2 designation.

8. Well condition, check all that apply. If yes, explain.

a. Severely deteriorated (or absent) surface casing: NO ☐ YES ☐

b. Severely deteriorated (or absent) production casing: NO ☐ YES ☐

Note: An affirmative response to both Questions 8a and 8b will result in an automatic Class

1 designation, otherwise Class 2.

9. Approximate well dates (if known):

Activity < 25 years 25 – 50 years > 50 years Approximate year

Well Construction ☐ ☐ ☐

Well Abandonment ☐ ☐ ☐

10. What is the proximate distance of the well to the nearest planned or active mineral development, check all that apply:

Mineral Resource 0 – 1000’ 1000-2000’ >2,000’

a. Oil ☐ ☐ ☐

b. Gas ☐ ☐ ☐

c. Coal ☐ ☐ ☐

d. Limestone ☐ ☐ ☐

Note: The presence of planned or active mineral development within 1,000’ of the subject well will result in an automatic Class 1 designation. Development within 2,000’ of the subject well results in a Class 2 designation.

11. What is the proximate distance of the well to the nearest water resource, check all that apply:

Water Resource 0 – 100’ 100-500’ >500’ Identity

a. Drinking water ☐ ☐ ☐

b. River/stream ☐ ☐ ☐

c. Lake/Reservoir ☐ ☐ ☐

12. Estimate number of people residing within 1,000’ of the well location:

0 – 20 > 20

a. Number of residents ☐ ☐

13. Current land use (check all that apply):

AGRICULTURAL ☐ COMMERCIAL ☐ RECREATIONAL ☐ RESIDENTIAL ☐

UNDEVELOPED ☐ OTHER: _____________________ ☐

14. Is there refuse or other debris on location? If yes, explain. NO ☐ YES ☐

V. Inspection certification

Inspection Date and Time: _______________

I hereby certify that all the information provided by me in this inspection report (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge.

I understand that the falsification, misrepresentation, or omission of any facts in said documents may be cause for non-payment under terms of the contract.

Signature:

Printed Name:

Title:

Date: