**[REGION 5 UIC CLASS II TECHNICAL REVIEW SHEET]{.underline}** (revised
9/18/96)

I. [HEADER INFORMATION]{.underline}

Permit

County\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Application #\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Twnshp, Rnge\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Operator\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_1/4 of\_\_\_\_1/4 of\_\_\_\_1/4 Sect\_\_\_\_\_
Well\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_Ft. from N/S line Quarter Section State Permit
#\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_Ft. from E/W line Quarter Section Permit
Writer\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Latitude \_\_\_\_E\_\_\_\_\'\_\_\_.\_\_\_\" North

Longitude \_\_\_\_E\_\_\_\_\'\_\_\_.\_\_\_\" West

II\. [WELL STATUS]{.underline}

Existing Date drilled \_\_\_/\_\_\_/\_\_\_

Converted Date converted \_\_\_/\_\_\_/\_\_\_

Circle one`   Proposed New`

    Proposed Conversion

III\. [AREA OF REVIEW]{.underline}

AOR map showing well(s) attached to application? \_\_\_\_\_\_\_

How many wells in the AOR penetrate the injection zone? \_\_\_\_\_\_

Of these wells, how many are:

T.A.\'ed. \_\_\_\_\_ Construction Adequate? \_\_\_\_\_

P.A.\'ed. \_\_\_\_\_ Construction Adequate? \_\_\_\_\_

Producers \_\_\_\_\_ Construction Adequate? \_\_\_\_\_

Injectors \_\_\_\_\_ Construction Adequate? \_\_\_\_\_

List submitted naming owner(s) of record within the AOR? \_\_\_\_\_\_

Map showing landowners within the AOR? \_\_\_\_\_\_

IV\. [UNDERGROUND SOURCES OF DRINKING WATER]{.underline}

Formation name of lowest
USDW:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Depth to USDW base: \_\_\_\_\_\_\_\_\_\_\_

Methods of USDW determination:

Atlas \_\_\_\_\_\_\_\_\_\_\_\_

Well control \_\_\_\_\_\_\_\_\_\_\_\_

Other \_\_\_\_\_\_\_\_\_\_\_\_

`V. ``	`[`GEOLOGIC DATA OF CONFINING AND INJECTION ZONE`]{.underline}

[Injection Zone]{.underline} [Confining Zone]{.underline}

Fm. Name(s) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Lithology \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Depth to top \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Thickness \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

What is the separation between the base of the lowest USDW and the top
of the injection zone? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

What method was used to determine maximum injection pressure?

\_\_\_\_\_\_\_ Field Rules (see Federal Register Notices

61084, 61910, 65711)

\_\_\_\_\_\_\_ Fracture Data: Use the ISIP pressure

(Attach fracture job charts etc.)

\_\_\_\_\_\_\_ Fracture gradient equation:

\[FG - (.433(Sg +.05))\] x depth - 14.7 = \_\_\_\_\_

(Sg = \_\_\_\_\_\_\_\_\_\_\_\_) from chemical analysis

(Depth = \_\_\_\_\_\_\_\_\_\_\_ft.)

(FG = \_\_\_\_\_\_\_\_\_\_\_\_\_\_psi/ft)

\_\_\_\_\_\_\_ Other (explain)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

VI\. [OPERATING DATA]{.underline}

Maximum permitted injection pressure:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Maximum permitted injection rate (BPD) (if applicable):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Specific gravity from chemical analysis:\_\_\_\_\_\_\_ +.05 =
\_\_\_\_\_\_\_

Composition of the annulus fluid:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

VII\. [WELL CONSTRUCTION]{.underline}

Total Depth \_\_\_\_\_\_\_\_\_\_\_ft. Plugged Back Total Depth
\_\_\_\_\_\_\_\_\_\_\_ft.

Formation at T.D. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Type of Completion:

Perforations depths \_\_\_\_\_\_\_\_\_\_\_ to \_\_\_\_\_\_\_\_\_\_\_ft.

Open hole depths \_\_\_\_\_\_\_\_\_\_\_ to \_\_\_\_\_\_\_\_\_\_\_ft.

Packer depth \_\_\_\_\_\_\_\_\_\_\_ft.

Packer to be set within or below the immediate confining
system?\_\_\_\_\_\_

Packer to be set within a cemented interval?\_\_\_\_\_\_

Cement interval adjacent to casing strings: (use 20% excess)

  ------- ----------- ----------- ---------------- ------------- -------- ------------------- -------- ---------------- -- -- -- -- -- -- -- ---------------- -- -- -- -- -- -- -- --------------------- -- -- -- -- -- -- -- -------------------- -- -- -- -- -- -- --
          Hole        Tubulars                                            Cemented Interval                                                                                                                                                                          
          Size (in)   Size (in)   Weight (lb/ft)   Depths (ft)            Depths (ft)                                                                                                                                                                                
                                                   Top           Bottom   Top                 Bottom   Conductor Pipe                        Surface Casing                        Intermediate Casing                        Long String Casing                     
  Liner                                                                                                                                                                                                                                                              
  ------- ----------- ----------- ---------------- ------------- -------- ------------------- -------- ---------------- -- -- -- -- -- -- -- ---------------- -- -- -- -- -- -- -- --------------------- -- -- -- -- -- -- -- -------------------- -- -- -- -- -- -- --

VIII\. [MECHANICAL INTEGRITY TESTING]{.underline}

[Part I Mechanical Integrity]{.underline}:

Type of MIT to be conducted upon well completion:

[Part II Mechanical Integrity]{.underline}:

\_\_\_\_\_\_ Cement

Proof of cement is/to be demonstrated by submitting:

\_\_\_\_\_\_ Signed State completion report

\_\_\_\_\_\_ Cementing tickets

\_\_\_\_\_\_ Cement Bond Log

\_\_\_\_\_\_ Temperature / Noise survey / Oxygen Activation Log

Other logs run:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

IX\. [PLUGGING AND ABANDONMENT]{.underline}

\_\_\_\_\_\_ All uncemented casing ripped.

\_\_\_\_\_\_ Plug of at least 250 feet set immediately above the top of
the injection zone.

\_\_\_\_\_\_ 50 feet of cement immediately above cast iron bridge plug.
250 feet is required above cement retainer if situated adjacent to the
injection zone.

\_\_\_\_\_\_ Cement plug set at least 50 feet above and 50 feet below
any rip point.

\_\_\_\_\_\_ **If surface casing is not cemented to surface**, cement
plug set at least 50 feet below the lowest USDW to surface.

\_\_\_\_\_\_ **If surface casing is cemented to surface** and extends
below the lowermost USDW, a cement plug from at least 50 feet above the
USDW base to 50 feet below the shoe is required and a cement plug from
at least 50 feet depth to the surface is required.

\_\_\_\_\_\_ **If surface casing is cemented to surface **and the
lowermost USDW is below the surface casing setting depth, a cement plug
from at least 50 feet below the USDW base to 50 feet above the casing
shoe is required and a cement plug from at least 50 feet depth to the
surface is required.

\_\_\_\_\_\_ **If the lowermmost USDW is less than 500 feet deep**, a
continuous cement plug is set from at least 50 feet below the base of
the lowermost USDW to the surface.

Explain any variation from the above:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

X. [COMPLIANCE WITH OTHER FEDERAL ACTS]{.underline}

**Wild and Scenic Rivers Act**: Any designated Wild and Scenic Rivers
within the quarter mile AOR? \_\_\_\_\_\_

If so, give name(s)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Endangered Species Act**:

Has the Permit Writer contacted U.S. Fish and Wildlife Service for a
list of Endangered or Threatened Species? \_\_\_\_\_\_

Written response from U.S. FWS? \_\_\_\_\_\_\_\_\_\_\_

Any listed species present? \_\_\_\_\_\_\_\_\_\_ If yes, list:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**National Historic Preservation Act**:

State Historic Preservation Office contacted? \_\_\_\_\_\_\_\_

Historic Resources present?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

    	

**Coastal Zone Management Act**:

Is the well located in a Michigan county which borders the Great Lakes?
\_\_\_\_\_\_

If \"yes\", then has the permit writer contacted the Michigan Coastal
Management Program (CMP) in writing? \_\_\_\_\_\_\_\_\_

If the Michigan CMP has not been contacted in writing and the well is
located in a Michigan county which borders the Great Lakes, then ensure
that the Michigan CMP office is included in the public notice list:

Ms. Cathy Cunningham, Land and Water Management Analyst

Michigan Department of Natural Resources

Division of Land and Water Management

Coastal Management Program, P.O. Box 30458

Lansing, Michigan 48909

**Fish and Wildlife Coordination Act**:

Does permit application call for diverting, impounding, deepening or
controlling any surface water body in excess of 10 acres?
\_\_\_\_\_\_\_\_\_\_

XI\. [FINANCIAL ASSURANCE]{.underline}

Type
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Amount
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Provider
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Standby Trust provided
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

If Blanket Bond coverage:

Is Form VII-10 acceptable? \_\_\_\_\_\_\_

Is the amount equal to 10 times the cost to plug the most expensive
injection well in the field or 75% of the total cost to plug all wells?
\_\_\_\_\_\_

List of all wells covered under the blanket bond provided?
\_\_\_\_\_\_\_

If State Bond Coverage:

Has a letter of intent to use this type of bond been submitted by the
operator? \_\_\_\_\_\_

Has a copy of the state bond been provided? \_\_\_\_\_\_\_\_\_\_

XII\. [CONFIDENTIALITY]{.underline}

Has any part(s) of this permit application been declared confidential by
the operator? \_\_\_\_\_\_\_.

If yes, then specify the confidential
parts:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Permit writer signature
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date:\_\_\_/\_\_\_/\_\_\_