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Form Approved. OMB No. 2040-0042. Expires 9-30-91 <br /> UNITED STATES ENVIRONMENTAL PROTECTION AGENCY <br /> t/ WASHINGTON,DC 20480 <br /> E PA <br /> ANNUAL DISPOSAL/INJECTION WELL MONITORING REPORT <br /> NAME AND ADDRESS OF EXISTING PERMITTEE NAME AND ADDRESS OF SURFACE OWNER <br /> STATE COUNTY PERMIT NUMBER <br /> LOCATE WELL AND OUTLINE UNIT ON <br /> SECTION PLAT — 640 ACRES <br /> N SURFACE LOCATION DESCRIPTION <br /> 1/4 OF '/4 OF 'A SECTION TOWNSHIP RANGE <br /> LOCATE WELL IN TWO DIRECTIONS FROM NEAREST LINES OF QUARTER SECTION AND DRILLING UNIT <br /> Surface <br /> Location—ft.from(N/S)_Lina of quarter section <br /> and—ft.from E _Line of quarter section <br /> WELL ACTIVITY TYPE OF PERMIT <br /> W E O Brine Disposal [3 Individual - <br /> ❑Enhanced Recovery ❑Area <br /> ❑Hydrocarbon Storage Number of Wells <br /> I I II Lease Name Well Number <br /> S <br /> TUBING—CASING ANNULUS PRESSURE <br /> INJECTION PRESSURE TOTAL VOLUME INJECTED (OPTIONAL MONITORING) <br /> MONTH YEAR AVERAGE PSIG MAXIMUM PSIG BBL MCF MINIMUM PSIG MAXIMUM PSIG <br /> CERTIFICATION <br /> I certify under the penalty of law that l have personally examined and am familiar with the information submitted in <br /> this document and all attachments and that,based on my inquiry of those individuals immediately responsible for <br /> obtaining the information,l believe that the information is true, accurate,and complete. l am aware that there are <br /> significant penalties for submitting false information, including the possibility of fine and imprisonment. (Ref. 40 <br /> CFR 144.32). <br /> NAME AND OFFICIAL TITLE(Please typo or print) SIGNATURE DATE SIGNED <br />