STATE OF TENNESSEE
DEPARTMENT OF ENVIRONMENT AND CONSERVATION
DIVISION OF WATER RESOURCES
TENNESSEE OIL AND GAS PROGRAM
711 R. S. GASS BLVD.
NASHVILLE, TENNESSEE 37216
SURFACE OWNERS NOTIFICATION CERTIFICATION
This is to certify that, _____________________________________(Operator Name), has given a notice to surface owners
as required under Tennessee Code Annotated, Title 60, Chapter 1, Part 2, Section 60-1-209 and Chapter 0400-52-02-.01(6) of the
Rules of the Tennessee Oil and Gas Board for the proposed __________________________________ Well No. _________ to
be Located ____________Latitude _____________Longitude
___________FNL, FSL ___________ FEL,FWL Sec __________ Carter Quad. __________ N,S __________ E,W by
certified mail, returned receipt requested, to the persons entitled to such notification as follows.
Surface Owner’s Name
Address
Date Notice Mailed
_______________
_______________________________________
_______________________________________
_______________
_______________
____________________________________
____________________________________
_______________
_______________
_______________________________________
_______________________________________
_______________
_______________
_______________________________________
_______________________________________
_______________
_______________
_______________________________________
_______________________________________
_______________
_______________
_______________________________________
_______________________________________
_______________
I hereby attest and affirm that the information included on or associated with this certification is true and accurate to
the best of my knowledge. I hereby authorize the State of Tennessee to make any contacts for verification of any
information included on or with this certification.
Please attach additional sheets if necessary.
SIGNATURE: ________________________________________________
Operator
CN-0694(Rev.07-13)
Page 1 of 1
RDA-1910