MISSISSIPPI STATE OIL & GAS BOARD

ORIGINAL WELL COMPLETION 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

DATE SPUDDED DATE TOTAL DEPTH REACHE DATE OF THIS COMPLETION ELEVATION (DF,RKB,RT or GR)

FEET

ELEVATION OF CASING HD. FLANGE

TOTAL DEPTH P.B.T.D SINGLE,DUAL OR TRIPLE COMPLETION? IF THIS IS A DUAL OR TRIPLE COMPLETION, FEET

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 RECORDS AND TEST RESULTS 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

TUBING PRESSURE CASING PRESSURE CALCULATED RATE OF PRODUCTION PER 24 HRS. OIL (Corr)

BBLS.

GAS

MCF

WATER

BBLS.

GAS - OIL RATIO

DISPOSITION OF GAS (State Whether Vented, Used for Fuel or Sold) SOUR GAS OR OIL

AMOUNT H2S: AMOUNT CO2:

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 the 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 recompletion report and well log shall be filed with the Mississippi State Oil and Gas Board no later than thirty (30) days after project

completion.