Form Center

Unconventional Gas Well Registration

2. Well Pad Information

4. Site (Farm) Name*

5. Status of Site*
   -- Select One --NewExisting

6. Municipality
   -- Select One --Bellefonte BoroughBenner TownshipBoggs TownshipBurnside TownshipCentre Hall BoroughCollege TownshipCurtin TownshipFerguson TownshipGregg TownshipHaines TownshipHalfmoon TownshipHarris TownshipHoward BoroughHoward TownshipHuston TownshipLiberty TownshipMarion TownshipMiles TownshipMilesburg BoroughMillheim BoroughPatton TownshipPenn TownshipPhilipsburg BoroughPort Matilda BoroughPotter TownshipRush TownshipSnow Shoe BoroughSnow Shoe TownshipSpring TownshipState College BoroughTaylor TownshipUnion TownshipUnionville BoroughWalker TownshipWorth Township

8. Location (Pad Center)*

   Latitude

9. Location (Pad Center)*

   Longitude

10. Intersection with Nearest Public Road*

    Latitude

11. Intersection with Nearest Public Road*

    Longitude

13. Nearest Public Road Name

14. Driving Directions to Well Pad

15. Sketch Plan of Access Road and Pad

19. 911 Addressing

21. Address Assigned

    1. Yes
    2. No

22. Assigned Street Address

26. Emergency Management

28. Chemicals Onsite*

    1. Yes
    2. No

30. Chemical Name

31. Quantity

33. Chemical Name

34. Quantity

36. Chemical Name

37. Quantity

39. Chemical Name

40. Quantity

42. Chemical Name

43. Quantity

45. Chemical Name

46. Quantity

48. Chemical Name

49. Quantity

51. Chemical Name

52. Quantity

54. Chemical Name

55. Quantity

59. Emergency Response Plan

61. Do You Have an Emergency Response Plan?

    1. Yes

    1. No

63. Upload Emergency Response Plan*

    Upload a copy of your Emergency Response Plan for this well pad

Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit Submit and Print

* indicates a required field