This government document is issued by Department of Environmental Protection for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:gul-_xwuyho&q=https://files.dep.state.pa.us/OilGas/BOGM/BOGMPortalFiles/OilGasReports/2012/NEWOilGasForms.pdf&sa=U&ved=2ahUKEwiOydOWq9X8AhVUTaQEHUw6CVk4PBAWegQIAxAB&usg=AOvVaw1mrt8Na8gd1dxdiRMOWBa0