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Form Approved. 0!M No. 2040-0042. Expires 9-30-91 <br /> UNITED STATES ENVIRONMENTAL PROTECTION AGENCY <br /> trRWASHINGTON.DC 204410 <br /> �4 sPA WELL REWORK RECORD <br /> NAME AND ADDRESS OF PERMITTEE -NAME AND ADDRESS OFCONTRACTOR <br /> -STATECOUNTY PERMIT NUMBER <br /> - _ <br /> LOCATE WELL AND OUTLINE UNIT ON = _ <br /> SECTION PIAT—640 ACRES <br /> 'SURFACE LOCATION DESCRIPTION z- <br /> N - ' OF ='A OV­t t - %SECTION - TOWNSHIP. RANGE <br /> LOCATE 1NELL Ml Tt+MO DIRECTIONS FROM`NEAREST LINES OF QUARTER SECTION AND DRILLING UNIT <br /> Location__h horn(M/SI Lina!#-I(- <br /> setxton <br /> ena_h h'omE' __Lx»of uiriers�euii =WELLACTIVITY Total D ptl Bsitore Rework �TYPE OF PERMIT <br /> O Brine Disposal O Individual <br /> W E O Enhanced Recovery Total Depth After Rework O Area <br /> ce <br /> O Hydrocarbon Storage Number of Wells <br /> Lease Name Date Rework Commenced (Well Number <br /> Date Rework Completed I <br /> 5 <br /> WELL CASING RECORD=BEFORE REWORK <br /> _ ca Cement Perforations Acid or Fracture <br /> I Depth Seeks Type From To Trestmem Record <br /> WELL CASING RECORD—AFTER REWORK(indicate Additions and Changes Only) <br /> Gsing <br /> Gmem' Perforations Acid or Fracture <br /> Size Depth Sacks Type From To Trestmem Record <br /> DESCRIBE REWORK OPERATIONS IN DETAIL - WIRE UNE LOGS,UST EACH TYPE <br /> USE ADDITIONAL SHEETS IF NECESSARY Log Types Logged Intervals <br /> CERTIFICATION <br /> /certify under the penalty of law that/have personally examined and am familiar with the information <br /> submitted in this document and all attachments and that, based on my inquiry of those individuals <br /> immediately responsible for obtaining the information, l believe that the information is true, accurate, <br /> and complete.l am aware that there are significant penalties for submitting false information,including <br /> the possibility of fine and imprisonment. (Ref. 40 CFR 144.32). <br /> NAME AND OFFICIAL TITLE(Please type or print/ SIGNATURE I DATE SIGNED <br />