## MARYLAND DEPARTMENT OF THE ENVIRONMENT Land Management Administration • Minerals, Oil & Gas Division 1800 Washington Blvd. • Baltimore Maryland 21230 (410) 537-3557 • 1-800-633-6101 • http://www.mde.state.md.us

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### 5 Form Number MDE/ L MA/PER. 019 Revis ion Date 9-26-2014 TTY Users 1-800-735-2258 r 

## OIL/GAS WELL COMPLETION REPORT

N a m e of O p erator Addres s Well N ame and Number Surveyed elevation (feet): KB G L Well Location Field (If wildcat, so state) Pool County Drilling contractor Date spudded Date drilling reached total depth Total depth: driller logger plugback Total depth in sidetracked hole (STH): driller logger plugback

Ki ck-off point: direction @ depth of

Resu ltant lateral direction

Bottom hole location
CASING AND LINER RECORD Casing t y pe Size Used in drilling Left in hole Depth set below: KB ____ G L ____ Permit No.

## MARYLAND DEPARTMENT OF THE ENVIRONMENT Land Management Administration • Minerals, Oil & Gas Division 1800 Washington Blvd. • Baltimore Maryland 21230 (410) 537-3557 • 1-800-633-6101 • http://www.mde.state.md.us

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### 5 Form Number MDE/ L MA/PER. 019 Revis ion Date 9-26-2014 TTY Users 1-800-735-2258 r CEMENT RECORD Si ze of Interval No. sacks Type Service hole cemented Date of cement cement Test Pressure Company to

S QUEEZE CEMENT RECORD Interval N o . S acks T y pe S ervice

s queezed Date of C e m ent C e m ent C o m p any to to to to
PERFORATION RECORD P erforation S ervice interval D ate H o le s /ft. S ize & T y pe C o m p any to to to to to to to to to to to to to

## MARYLAND DEPARTMENT OF THE ENVIRONMENT Land Management Administration • Minerals, Oil & Gas Division 1800 Washington Blvd. • Baltimore Maryland 21230 (410) 537-3557 • 1-800-633-6101 • http://www.mde.state.md.us

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### 5 Form Number MDE/ L MA/PER. 019 Revis ion Date 9-26-2014 TTY Users 1-800-735-2258 S ize N a m e & T y pe D epth s et

S ize W eight range N a m e & t y pe D epth s et D ate Te s t P r e ss u re

S ervice Process Interval Date Material & Quantity Pressure C o m p any t o to to to

DRILL S TEM TE S T RECORD Test date Interval Type and volume of fluids recovered (oil, gas, water, etc.)
t o t o t o t o TUBING RECORD

MECHANICAL PLUG AND PACKER RECORD

WELL STIMULATION AND TREATMENT RECORD

## MARYLAND DEPARTMENT OF THE ENVIRONMENT Land Management Administration • Minerals, Oil & Gas Division 1800 Washington Blvd. • Baltimore Maryland 21230 (410) 537-3557 • 1-800-633-6101 • http://www.mde.state.md.us

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### 5 Form Number MDE/ L MA/PER. 019 Revis ion Date 9-26-2014 TTY Users 1-800-735-2258 GEOPHYSICAL LOG RECORD Interval logged: maximum depth minimum depth Interval logged STH: maximum depth minimum depth If well not logged to total depth explain why : Log ty pes: induction, resistivity, sonic, neutron, density, gamma ray, dipmeter, direc tional, bond, flowmeter, temperature, rad ioactive tracer, etc. including computer generated logs. Ty pe Date run Interval logged F rom to feet F rom to feet F rom to feet F rom to feet F rom to feet F rom to feet F rom to feet
CORE RECORD Cored: from to feet; recovered feet
to feet; recovered feet
to feet; recovered feet
to feet; recovered feet Were sidewall cores taken: y es no If yes complete the following: N umber taken: from to feet
SAMPLE RECORD S amples collected: from to feet; recovered feet and from to feet; recovered feet and from to feet; recovered feet

## MARYLAND DEPARTMENT OF THE ENVIRONMENT Land Management Administration • Minerals, Oil & Gas Division 1800 Washington Blvd. • Baltimore Maryland 21230 (410) 537-3557 • 1-800-633-6101 • http://www.mde.state.md.us

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### 5 Form Number MDE/ L MA/PER. 019 Revis ion Date 9-26-2014 TTY Users 1- 800-735-2258 GEOLOGICAL LOG G eologic formation Top Bottom Gas at Oil at Water at Remarks



### This completion report is true and correct to the best of my knowledge.

Date Signature

Com pany
This Notice is provided pursuant to § 10-624 of the State Government Article of the Maryland Code. The personal information requested on this form is intended to be used in processing your application. Failure to provide the information requested may result in your application not being processed. You have the right to inspect, amend, or correct this form. The Maryland Department of the Environment (“MDE”) is a public agency and subject to the Maryland Public Information Act (Md. Code Ann., State Gov't §§ 10-601, et seq.). This form may be made available on the Internet via MDE’s website and is subject to inspection or copying, in whole or in part, by the public and other governmental agencies, if not protected by federal or State law.