NCC223353_FRO Submitted_20221003

Noah Carolina Department of Environment and Natural Resources
Division of Energy, !Mineral, and hand Resources
Energy Section - Oil and Gas program
Form 1612 Mail Service Center, Raleigh, NC 27699-1612
Phone: [phone]
Fax: [phone]
Rev 03/2015 Email: [e-mail]
Financial Responsibility Ownership
Applicant or Z �1� lNl _ iniLi:�T5 u? L.i--4
Permittee Name: kV! s4 NT . k I Phone:
Company Name: 1•l{��'v���,��,��i St' �.`e ..,,
Address: �•'� � e �. �'� . C—. O -C k P d
City:
Lease/Well Name:mm
Well Number: County:
Commission Issued
Drilling Unit Number:
Fax:
4
On
Date:
Received by:
Document ID:
State: Zip:
Nearest Town/
�
City: �r
Well Site Ingress/
Egress Location:
Approximate Date Land Disturbing Activities Will Commence: Total Acreage of Disturbed or Uncovered Areas:
75A NCAC 05H .1302
Provide the name, phone number, and Email address for the person to contact onsite if problems occur with erosion control,
stormwater, and any oil and gas well site operations:
Name: 3 LL5 ,RA A, Dean I Phone: 11
Email: te ij G A"f-ej � 63 L-1
List all individuals approved to submit documents on behalf of the applicant or permittee and individuals designated as an agents)
of the financially responsible party;
Name: � 11 0rr-e'1 Title: STD
Name: "v rC' Ed 1'kA e)' M+" iC Title: -r's 4
Name: Title:
Name: Title:
Page F

Form 1 - Financial Responsibility Ownership Rppllcant or
Permittee Name:
Provide the name, address, phone number, fax number, and Email address for the person who is financially responsible for oil and gas
operations:
Name: Phone:
Address: Fax:
Email:
Attach a copy of the Certificate of Assumed Name if the financial responsible party is a partnership or other person engaging in
business under an assumed name:
❑ Check Box to indicate Certificate of Assumed Name is attached by email or with hardcopy of this form.
If file is attached with email submittal, please write the name of the file.
Notary Public Information:
I, a Notary Public of the County of ate���
State of North Caro lina, hereby certify that
appeared personally before me this day and being duly sworn acknowledge that the above form was executed by him/her.
Witness my d and notarias20
t.
My commission expires
:.
This form must tie signed by the financially responsible party.
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