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8000-FM-OOGM0004a Rev.

12/2015
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OFFICE OF OIL AND GAS MANAGEMENT

DEP USE ONLY
Site ID

Well Record

Client Id

     

     

Client Id

Sub Facility Id

     

     

WELL INFORMATION
Well Operator

Well API #

     

37-   -     -  -  

     

DEP ID#

  °  ‫׳      ״‬
LONG -   °  ‫׳      ״‬

Address

LAT

     
City

     
Phone

State

Zip

     

           

Municipality

Fax

Gas

Well Orientation

Oil

Vertical

Drill Method(s)

     

Project Number

Serial #

     

     

     
USGS 7.5 min. quadrangle map
     

     
Original Well Record

Combination Oil & Gas

Well #

     

County

Email

     
     
Check the appropriate Submission:
Well Type

NAD 83

Well Farm Name

Amended Well Record

CBM

Injection

Disposal

Storage

Deviated from Vertical (Top & Side views & Deviation Survey must be attached)

Rotary – Air      ’

Section

Rotary – Mud      ’

Cable Tool      ’

Drilling Started      

Surface Elev.       ft.

GW Depth       ft.

Drilling Complete      
Date Well Completed      

True Vertical Depth       ft.
Total Measured Depth       ft.

Depth of DFGW      ft.
DFGW decided by: 0

Wellbore Conditioning:
     

Other      ’

CEMENT
If No, provide depth to top of cement and method used to determine :

No

If No, provide depth to top of cement and method used to determine:

Cement returned on intermediate casing?

Yes

No

If No, provide depth to top of cement and method used to determine:

Casing String

Type/Class of Cement
(Lead/Tail)

Slurry
Temp F°

Amount of Cement (sks) (Lead/Tail/Total)

     
     
     

NA
NA
Gas Migration
Controls Used

/sk

No

Yes

Yld /ft3

Yes

Cement returned on coal protective casing?

Wt PPG

Cement returned on surface casing?

What controls were used if any
(additives/ hardware. Specify type and
depth applicable).

Conductor

      /      

    °

      /       /      

    

           

Surface

      /      

    °

      /       /      

    

                 

Coal Protective

      /      

    °

      /       /      

    

           

Intermediate

      /      

    °

      /       /      

    

           

Production

      /      

    °

      /       /      

    

           

     

      /      

    °

      /       /      

    

           

If additional strings
attach form(s)

     

Total

CASING AND TUBING
Thread /
Grade Casing Weld –
Amount in
/ Tubing Type New/ Used Well (ft.)

Hardware - Baskets / Packer / Centralizers
(Total/String)
Type
Size
Depth

Hole
Size

Pipe
Size

Wt.
#/ft.

CO

R

     

     

     

     

 - 

     

  

     

     

     

     

     

     

     

     

 - 

     

  

     

     

     

     

     

     

     

     

 - 

     

  

     

     

     

     

     

     

     

     

 - 

     

  

     

     

     

     

     

     

     

     

 - 

     

  

     

     

     

     

Date Run

If any casing is welded, provide the name(s) of the welder(s):      

PLUG-BACK/WELLBORE ALTERATION
Fill Material & Plugs

Depth

Size

Casing & Tubing
Pulled

Left

     

     

     

     

     

     

     

     

     

     
     

     
     

     
     

     
     

     
     

From

To

     

     

     

     

     

     
     

     
     

-1-

Date

12/2015 LOG OF FORMATIONS -2- Well API#: 37-   -     -  -   .8000-FM-OOGM0004a Rev.

000 psi has passed a pressure test in accordance with 25 Pa.) Formation Name Top Bottom or Lithology (feet) (feet)       ----------0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 If no show of oil. In addition.8000-FM-OOGM0004a Rev. address.Zip                Printed Name / Title:       /       Date:       Phone       -3- Date: Comments:       . and telephone number of all well service companies involved. I do hereby certify that any casing which is attached to a blow-out preventer with a pressure rating greater than 3. information and belief that the well identified on this Well Record has been properly cased and cemented in accordance with the requirements of 25 Pa.)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Source of Data                                                                                                                                                                                     WELL SERVICE COMPANIES (Provide the name. 12/2015 (If you will need more space than this page. explain why:       Gas at Oil at Water at (feet) (feet) (fresh / brine. Code §78.) Casing Source Cementing Company Hardware Supplier Logging Company Name Name Name Name                         Address Address Address Address                         City – State – Zip City – State – Zip City – State – Zip City – State – Zip                                              Phone Phone Phone Phone                                        I do hereby certify to the best of my knowledge. I am aware that there are significant penalties for submitting false information. Driller Well Operator’s Signature Name Rig             DEP USE ONLY Reviewed by:       Address       City – State. including the possibility of fine and imprisonment. Code Chapter 78 and any conditions contained in the permit for this well.84(f). please photocopy the blank form before filling it in. ft. gas or water.