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Form Approved. OMB No. 2040-0042. Expires 9-30-91 <br /> UNITED STATES ENVIRONMENTAL PROTECTION AGENCY <br /> A WASHINGTON,DC 20460 <br /> E PH WELL REWORK RECORD <br /> AND ADDRESS OF PERMITTEE NAME AND ADDRESS OF-CONTRACTOR <br /> STATE COUNTYPERMIT NUMBER <br /> LOCATE WELL AND OUTLINE UNIT ON <br /> SECTION PLAT—640 ACRES 1 <br /> SURFACE LOCATION DESCRIPTION <br /> N '4 OF '/a OF '.4 SECTION TOWNSHIP RANGE <br /> LOCATE WELL IN TWO DIRECTIONS FROM NEAREST LINES OF QUARTER SECTION AND DRILLING UNIT <br /> Surface <br /> ' Location_h.from JN/S)_Line of quarter section <br /> and—ft.from E _Line of quarter section <br /> - -�--�- -�- WELL ACTIVITY Total Depth Before Rework TYPE OF PERMIT <br /> 0 Brine Disposal 0 Individual <br /> W E 0 Enhanced Recovery 0 Area <br /> 0 Hydrocarbon Storage Total Depth After Rework Number of Wells <br /> ' I Lease Name Date Rework Commenced I Well Number <br /> Date Rework Completed <br /> S <br /> WELL CASING RECORD :.-BEFORE REWORK <br /> Casing Cement Perforations Acid or Fracture <br /> Size Depth Sacks Type From To Treatment Record <br /> } <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 /> l 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. lam 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 prrnti SIGNATURE DATE SIGNED <br />