# MISSISSIPPI STATE OIL & GAS BOARD ORIGINAL WELL CO MPLETION AND/ OR RECOMPLETION REPORT AND WELL LOG FORM 3 INDICATE TYPE OF COMPLETION NEW WELL REENTRY WORKOVER DEEPEN PLUG BACK SAME RESERVOIR DIFFERENT RESERVOIR OIL GAS INJECTOR DRY 

### DESCRIPTION OF WELL AND LEASE OPERATOR ADDRESS LEASE NAME WELL NUMBER FIELD & RESERVOIR LOCATION SEC. - TWN. - RGE, LAT AND LONG API NO. DIRECTIONAL, VERTICAL OR HORIZONTAL COUNTY PERMIT NUMBER DATE ISSUED PREVIOUS PERMIT NUMBER DATE ISSUED D A T E S P U D D E D D A T E T O T A L D E P T H R E A C H E D A T E O F T H I S C O M P L E T I O N E L E V A T I O N ( D F , R K B , R T o r G R ) FEET ELEVATION OF CASING HD. FLANGE FEET TOTAL DEPTH P.B.T.D SINGLE,DUAL OR TRIPLE COMPLETION? IF THIS IS A DUAL OR TRIPLE COMPLETION, FURNISH SEPARATE REPORT FOR EACH COMPLETION. PERFORATIONS FOR THIS COMPLETION, FORMATION DRILLING CONTRACTOR WAS THIS WELL DIRECTIONALLY DRILLED? WAS DIRECTIONAL SURVEY MADE? WAS COPY OF DIRECTIONAL SURVEY FILED? DATE FILED LIST ALL ELECTRICAL LOGS RUN FOR THIS COMPLETION, SERVICE COMPANY AND DATES FILED



### CASING RECORD CASING (Report All Strings Set in Well - Conductor, Surface, Intermediate, Producing, etc.) PURPOSE SIZE HOLE DRILLED SIZE CASING SET WEIGHT (lb./ft.) DEPTH SET SACKS CEMENT AMOUNT PULLED



### TUBING RECORD LINER RECORD SIZE IN. DEPTH SET FT. PACKER SET AT FT. SIZE IN. TOP FT. BOTTOM FT. SACKS CEMENT SCREEN FT. 

### PERFORATION RECORD THIS COMPLETION ACID, SHOT, FRACTURE, CEMENT SQUEEZE RECORD NUMBER PER FEET SIZE & TYPE DEPTH INTERVAL SERVICE COMPANY AMOUNT & KIND OF MATERIAL USED DEPTH INTERVAL



### LIST ALL OTHER PERFORATIONS RECORD S AND TEST RES ULTS CONT ON BACK ACID, SHOT, FRACTURE, CEMENT SQUEEZE RECORD NUMBER PER FEET SIZE & TYPE DEPTH INTERVAL SERVICE COMPANY AMOUNT & KIND OF MATERIAL USED DEPTH INTERVAL



### INITIAL PRODUCTION DATE OF FIRST PRODUCTION /INJECTION PRODUCING METHOD (Indicate if Flowing, Gas Lift or Pumping - If Pumping, Indicate Size & Type of Pump) DATE OF TEST HOURS TESTED CHOKE SIZE OIL PRODUCED DURING TEST BBLS. GAS PRODUCED DURING TEST MCF WATER PRODUCED DURING TEST BBLS. OIL GRAVITY °API (Corr) TUBING PRESSURE CASING PRESSURE CALCULATED RATE OF PRODUCTION PER 24 HRS. OIL BBLS. GAS MCF WATER BBLS. GAS - OIL RATIO DISPOSITION OF GAS (State Whether Vented, Used for Fuel or Sold) SOUR GAS OR OIL AMOUNT H 2 S: AMOUNT CO 2 : 

### Executed this the day of , 20____________ State of ___________________________________________________

___________________________________ County of Signature of Affiant

Before me, the undersigned authority, on this day personally appeared known to me to be the person whose name is subscribed to the above instrument, who being by me dully sworn on oath, states that he is duly authorized to make th e above report and that he has knowledge of the facts stated therin, and that said report is true and correct.

Subscribed and sworn to before me this day of , 20______________ SEAL Signature______________________________________________________ Notary Public in and for_________

________________________________ County_____________________________________

___________________ My commission expires :_______________________________________

CASING TESTS, REQUIRED BY STATEWIDE RULES 11 AND 12, MUST BE MADE. 

## Effective Jan. 1, 2007, no authorization to transport Oil or Gas from location will be approved until a completed form 3 and all electrical surveys have been filed with the Mississippi Oil and Gas Board. MISSISSIPPI STATE OIL AND GAS BOARD FORM NO. 3 A.P.I. WELL NUMBER STATE COUNTY WELL

## DETAIL OF FORMATIONS PENETRATED FORMATION TOP BOTTOM DESCRIPTION REQUIRED*

LIST ALL PERFORATONS WITH TEST DATA, ACID, FRACTURE, SQUEEZE, PLUGS

CORE RECORD DIAMOND CORE INTERVAL LIST ALL SIDEWALL CORES

OPEN HOLE TESTS DRILL STEM TEST INTERVAL DEPTHS RECOVERY PRESSURES



## * Show all important zones of porosity; detail of all cores; and all drill - stem tests, including depth interval tested, cushion used, time tool open, flowing and shut - in pressures, and recoveries. INSTRUCTIONS Attach all Well Logs. This well completion or rec ompletion report and well log shall be filed with the Mississippi State Oil and Gas Board no later than thirty (30) days after project completion.