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OMB No.2040-0042 Approval Expires 4/30107 <br /> United States Environmental Protection Agency <br /> ZVEPA Washington,DC 20460 <br /> COMPLETION REPORT FOR BRINE DISPOSAL, <br /> HYDROCARBON STORAGE, OR ENHANCED RECOVERY <br /> Name and Address of Existing Permittee Name and Address of Surface Owner <br /> i t <br /> State _„ Cou _) <br /> Locate Well and Outline Unit on My Permit Number <br /> Section Plat-640 Acres I <br /> _F <br /> N Surface Location Description <br /> 1/4 of 114 of 114 of 114 of Section Township Range <br /> — — — — Locate well in two directions from nearest lines of quarter section and drilling unit <br /> Surface <br /> I� IFI —T Location ft.frm(NIS) Line of quarter section <br /> and ft.from(E/W)`Line of quarter section. <br /> W E WELL ACTIVITY TYPE OF PERMIT <br /> ❑ Brine Disposal ❑ Individual Estimated Fracture Pressure <br /> Enhanced Recovery I,._ Area of Injection Zone <br /> F—T — _j Hydrocarbon Storage Number of Wells <br /> — — — — Anticipated Daily Injection Volume(Bbls) Injection Interval <br /> Average _ Maximum Feet to Feet <br /> S <br /> Anticipated Daily Injection Pressure(PSI) Depth to Bottom of Lowermost Freshwater <br /> Averaqe Maximum Formation(Feet) <br /> Type of Injection Fluid (Check the appropriate block(s)) Lease Name Well Number <br /> ❑ Salt Water I_ ! Brackish Water _ Fresh Water <br /> Name of Injection Zone <br /> Liquid Hydrocarbon Other <br /> Date Drilling Began Date Well Completed Permeability of Injection Zone <br /> Date Drilling Completed Porosity of Injection Zone <br /> CASING AND TUBING CEMENT HOLE <br /> OD Size Wt/Ft-Grade-New or Used Depth Sacks Class Depth Bit Diameter <br /> INJECTION ZONE STIMULATION WIRE LINE LOGS,LIST EACH TYPE <br /> Interval Treated Materials and Amount Used Log Types Logged Intervals <br /> Complete Attachments A--E listed on the reverse. <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 7520-10 (Rev.8-01) <br />