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OMB No.2040-0042 Approval Expires 4/30/07 <br /> United Stales Environmental Protection Agency <br /> V/EPA Washington,DC 20460 <br /> WELL REWORK RECORD <br /> Name and Address of Permittee Name and Address of Contractor <br /> Locale Well and Outline Unit on State County Permit Number <br /> Section Plat-640 Acres <br /> N Surface Location Description <br /> I _1/4 of 1/4 of 114 of 1/4 of Section_ Township Range,,,,_,_y <br /> 1_L 1_ 1_L 1_ Locate well in two directions from nearest lines of quarter section and drilling unit <br /> Surface <br /> Location ft.frm(NIS)_Line of quarter section <br /> 1_L1_ .1_L1_ <br /> and _ft.from(E/W)'�Line of quarter section. <br /> WELL ACTIVITY TotalDepth Before Rework TYPE OF PERMIT <br /> ... <br /> W E _ ..._...... <br /> 1_L 1_ 1_L _ ; Brine Disposal _ Individual <br /> Enhanced Recovery Total Depth After Rework _ Area <br /> Hydrocarbon Storage Number of Wells _ <br /> I Date Rework Commenced <br /> 1 L—L —L—L d_ Lease Name <br /> ..._.... _.- Well Number <br /> Date Rework Completed <br /> S <br /> WELL CASING RECORD--BEFORE REWORK <br /> Casing Cement Perforations <br /> Acid or Fracture <br /> Size Depth Sacks Type From To Treatment Record <br /> WELL CASING RECORD--AFTER REWORK (Indicate Additions and Changes Only) <br /> Casing Cement Perforations Acid or Fracture <br /> Size Depth Sacks Type From To Treatment Record <br /> DESCRIBE REWORK OPERATIONS IN DETAIL WIRE LINE LOGS,LIST EACH TYPE <br /> USE ADDITIONAL SHEETS IF NECESSARY Log Types Logged Intervals <br /> Certification <br /> I certify under the penalty of law that I have personally examined and am familiar with the information submitted in this document and all <br /> attachments and that,based on my inquiry of those individuals immediately responsible for obtaining the information,I believe that the <br /> information is true,accurate,and complete. I am aware that there are significant penalties for submitting false information,including the <br /> possibliity of fine and imprisonment. (Ref.40 CFR 144.32) <br /> Name and Official Title (Please type or print). Signature Date Signed <br /> EPA Form 7520-12 (Rev,8-01) <br />