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OMB No.2040-0042 Approval Expires 4/30/07 <br /> United States Environmental Protection Agency <br /> NEPA Washington,DC 20460 <br /> PLUGGING AND ABANDONMENT PLAN <br /> Name and Address of FpcjIjtK„ Name and Address of Owner/Operator <br /> State County ,_. ___ --------- PermltNumber <br /> Locate Well and Outline Unit on -- --• •-- <br /> Section Plat-640 Acres <br /> N Surface Location Description <br /> 114 of_1/4 of 1/4 of_ 1/4 of Section_ Township_ Range <br /> 1—`_L— -—`d— Locate well in two directions from nearest lines of quarter section and drilling unit <br /> I I I I I <br /> _—�__— _—�__— Surface <br /> Location ft.frm(NIS) Line of quarter section <br /> I I I I I I and_ft.from(E/W) Line of quarter section. <br /> TYPE OF AUTHORIZATION WELL ACTIVITY <br /> W E , <br /> 1 <br /> 7; Individual Permit 1❑ CLASS I— — 1—L 1— I Area Permit I CLASS II <br /> I I I I I I <br /> — — — — I Rule F I Brine Disposal <br /> 1_L 1_ 1_L 1_ _ I Enhanced Recovery <br /> Number of Wells <br /> I I I I I I I I Hydrocarbon Storage <br /> - I CLASS III <br /> ) <br /> S I <br /> Lease Name ': Well Number <br /> CASING AND TUBING RECORD AFTER PLUGGING METHOD OF EMPLACEMENT OF CEMENT PLUGS <br /> SIZE WT(LB/FT) TO BE PUT IN WELL(FT) TO BE LEFT IN WELL(FT) HOLE SIZE I� The Balance Method <br /> I� The Dump Bailer Method <br /> The Two-Plug Method <br /> �I Other <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(inche <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 III) <br /> LIST ALL OPEN HOLE AND/OR PERFORATED INTERVALS AND INTERVALS WHERE CASING WILL BE VARIED(if any) <br /> From To From To <br /> Estimated Cost to Plug Wells <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 /> possibility of fine and imprisonment. (Ref.40 CFR 144.32) <br /> Name and Official Title (Please type or print) Signature Date Signed <br /> EPA Form 7520-14 (Rev.8-01) <br />