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OMB No.2040-0042 Approval Expires 4/30/07 <br /> United States Environmental Protection Agency <br /> VvEPA Washington,DC 20460 <br /> ANNUAL DISPOSAL/INJECTION WELL MONITORING REPORT <br /> Name and Address of Existinq Permittee Name and Address of Surface Owner <br /> _ <br /> Locate Well and Outline Unit on State ounty Permit Number <br /> ---------- <br /> Section Plat-640 Acres C <br /> N Surface Location Description <br /> _114 of 1/4 of 114 of_114 of Section_ Township Range <br /> I—L 1— 1—`1— Locate well in two directions from nearest lines of quarter section and drilling unit <br /> I I I I I I <br /> —��— -t �— Surface <br /> Location ft.frm(N/S)_Line of quarter section <br /> 1— — — — and ft.from(E/W) Line of quarter section. <br /> I I I I I I <br /> W E WELL ACTIVITY TYPE OF PERMIT <br /> 1_L 1_ 1_L 1_ L_; Brine Disposal f_. Individual <br /> I I II� Enhanced Recovery Area <br /> Hydrocarbon Storage Number of Wells <br /> I I I I 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 /> s <br /> { E <br /> ( i <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 printf Signature Date Signed <br /> EPA Form 7520-11 (Rev.8-01) <br />