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Form Approved.OMB No.2040.0042.Aoprovat e.cotres 9-30-91 <br /> UNITED STATES ENVIRONMENTAL PROTECTION AGENC):. <br /> s A WASHINGTON,DC 20460 <br /> a"yE PA PLUGGING AND ABANDONMENT PLAN <br /> "'AME AND ADDRESS OF FACILITY NAME AND ADDRESS OF OWNER/OPERATOR <br /> STATE COUNTY I PERMIT NUMBER <br /> LOCATE WELL AND OUTLINE UNIT ON <br /> SECTION PLAT — 640 ACRES <br /> SURFACE LOCATION DESCRIPTION <br /> N 'A OF �/A OF 1/.SECTION TOWNSHIP RANGE <br /> I LOCATE WELL IN TWO DIRECTIONS FROM NEAREST LINES OF QUARTER SECTION AND DRILLING UNIT <br /> + Surface <br /> Location_ft.from(N/S)_Line of quarter section <br /> I I and_ft.from E _Line of quarter section <br /> TYPE OF AUTHORIZATION WELL ACTIVITY <br /> I I ❑Individual Permit ❑CLASS I <br /> W E ❑Area Permit ❑CLASS 11 <br /> 0 Rul, ❑Brine Disposal <br /> ❑Enhanced Recovery <br /> Number of Wells ❑Hydrocarbon Storage <br /> ❑CLASS III <br /> —L jI � <br /> S Lease Name Wel(Number i 1 <br /> i <br /> CASING AND TUBING RECORD AFTER PLUGGING METHOD OF EMPLACEMENT OF CEMENT PLUGS 1 <br /> ❑The Balance Method <br /> SIZE WT(LB/FT) TO BE PUT IN WELL(FT) TO BE LEFT IN WELL(FT) HOLE SIZE ❑The Dump Bailer Method <br /> ❑The Two-Plug Method <br /> ❑Other <br /> j <br /> CEMENTING TO PLUG AND ABANDON DATA: PLUG#1 PLUG#2 PLUG#3 PLUG#4 PLUG#5 PLUG#6 PLUG#7 <br /> Size of Hole or Pipe in which Plug Will Be Placed(inches) <br /> Depth to Bottom of Tubing or Drill Pipe(ft.) <br /> Sacks of Cement To Be Used(each plug) <br /> Slurry Volume To Be Pumped(cu.ft.) <br /> Calculated Top of Plug(ft.) <br /> Measured Top of Plug(if tagged ft.) <br /> Slurry Wt.(Lb./Gal.) <br /> Type Cement or Other Material Class 111 i <br /> LIST ALL OPEN HOLE AND/OR PERFORATED INTERVALS AND INTERVALS WHERE CASING WILL BE VARIED(1/anyl <br /> From To From To <br /> Estimated Cost to Plug Wells <br /> CERTIFICATION <br /> /certify under the penalty of law that l have personally examined and am familiar with the information <br /> 1 submitted in this document and al/ 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./am aware that there are significant penalties for submitting false information,including <br /> the possibility of fine and imprisonment. (Ref. 40 CFR 144.32) I <br /> NAME AND OFFICIAL TITLE(Please type or print) SIGNATURE DATE SIGNED <br />