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 

Form Number MDE/LMA/PER. 019 Page 1 of 5

Revision Date 9-26-2014

TTY Users 1-800-735-2258 r 

OIL/GAS WELL COMPLETION REPORT 

Name of Operator 

Address 

Well Name and Number Surveyed elevation (feet): KB GL 

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 

Kick-off point: direction @ depth of 

Resultant lateral direction 

Bottom hole location 

CASING AND LINER RECORD

Casing type Size Used in drilling Left in hole Depth set below: KB ____ GL ____ 

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 

Form Number MDE/LMA/PER. 019 Page 2 of 5

Revision Date 9-26-2014

TTY Users 1-800-735-2258 r 

CEMENT RECORD

 Size of Interval No. sacks Type Service 

 hole cemented Date of cement cement Test Pressure Company 

 to 

 

 

SQUEEZE CEMENT RECORD 

 Interval No. Sacks Type Service 

 squeezed Date of Cement Cement Company

 to 

 to 

 to 

 to 

PERFORATION RECORD 

 Perforation Service 

 interval Date Holes/ft. Size & Type Company

 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 

Form Number MDE/LMA/PER. 019 Page 3 of 5

Revision Date 9-26-2014

TTY Users 1-800-735-2258 

Size Name & Type Depth set 

Size Weight range Name & type Depthset Date Test Pressure 

Service 

Process Interval Date Material & Quantity Pressure Company

to 

 to 

 to 

to 

DRILL STEM TEST RECORD 

Test date Interval Type and volume of fluids recovered (oil, gas, water, etc.) 

to 

to 

to 

to 

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 

Form Number MDE/LMA/PER. 019 Page 4 of 5

Revision 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 types: induction, resistivity, sonic, neutron, density, gamma ray, dipmeter, directional, bond, flowmeter, temperature, radioactive 

tracer, etc. including computer generated logs. 

Type Date run Interval logged 

From to feet 

From to feet 

From to feet 

From to feet 

From to feet 

From to feet 

From 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: yes no If yes complete the following: 

Number taken: from to feet 

SAMPLE RECORD

Samples 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 

Form Number MDE/LMA/PER. 019 Page 5 of 5

Revision Date 9-26-2014

TTY Users 1-800-735-2258 

GEOLOGICAL LOG 

Geologic 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 

 Company

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.