COMMONWEALTHOFKENTUCKYDEPARTMEl'ffFORNATURALRESOURCESDIVISIONOFOILANDGAS'"-w"·,dogc.ky.govP.0.Box2244Frankfort,KY40601Phone:(502)573·0147Fax:(502)573-1099FOROFFICIALUSEONLYBondNo:UICPermitNo.:WELLRE-WORKREPORT0BrineDisposal0EnhancedReconry0HydrocarbonStorageWellOwner/Opcnator:-----------------------------StreetPcnnanentAddress:.______CityState:ZipCode:Phone:.______Email:------FannName:WellNumber:______County:______Carter0FNL0FELCoordinatc:s:nFSL____..O_.FWLSEC__LTR__NO.__DateRe-workCommenced:.____D11tcRe-workCompleted:.____..--WEILCASINGRECORDBEFOREREWORKACIDORFRACTURECASINGCEMENTPERFORATIONSTREATMENTRECORDSSizeDepthSacksTypeFromToWELLCASINGRECORDAFTERREWORK(IndicateAdditionsorChangesOnf.J")--ACIDORFRACTURECASINGCEMENTPERFORATIONSTREATMENTRECORDSSizeDenthS11cksTvneFromToGEOPHYSICALLOGSRANLOGGEDINTERVALSCERTIFICATIONIcertifyunderthepenaltyoflawthatIhnepersonallyenmlnedandamf•mlllarwiththeInformationsubmittedInthisdocumentandallattachmentsandthatbasedonmyInquiryofthoseIndividualsImmediatelyresponsibleforobtainingtheInformation,IbelievethattheInformationIstrue,accurate,andcomplete.AuthorizedAgent:Title:.____________PrintName:Signature:.________________Date:._________Sworntoandbefore:me:this__dayof____.20__NotaryPublicFORMED-4(8107)COMMONWEALTHOFKENTUCKYDEPARTMENTFORNATURALRESOURCESDIVISIONOFOILANDGAS"ww.doge.ky.govP.0.Box2244Frankfort,KY40601Phone:(502)513-0147Fax:(502)FOROFFICIALUSEONLYRecordNo.:AORMapReview:USDWReview:VICPermllNo.:CLASSIIWELLPERI\IITAPPLICATIONFORUNDERGROUNDINJECTIONCONTROLI.To0Drill,0Deepen,DConvmionofOil&GnsWelltoInjectionWell.PreviousPermitNo.2.InjectionWellType:0ENHANCEDRECOVERYAPPLICATION0DISPOSALAPPLICATION0HYDROCARBONSTORAGE3.WellOwner/Operator:-----------------------------4._________Stm:tCity5.State;----ZipCode:----Phone;._______Email:----------6.MineralOwner(Lessor):----------------WellNumber:------7.StreetCityZipPhone0FNL0FELCountyCaner8.Coordinates:____..O_,FSL____..O_,FWLSEC.__LTR.__NO.__9.ApproximatedepthofUndergroundSourceofDrinkingWater(USDW):_______.measurestoinsureprotectionofUSDWfrominjectionoperationsIIJ'Ctobedetailed(secquestion19.sectionD).10.NameofField:------------·II.NameofGeologieInjectionzone:Depth:Top___Bottom__.12.ProposedTollllDepth:ifexistingwell;todepthof______13.Injectionmethod:DThroughPerforationsDPackeronTubingAssembly14.Ifpackerontubingnssemblyisused,depthpackerisset:nottoexceedfifty(50)feelaboveinjectionzone.I5.Estimatedformationbreakdownpressure::.____psig.16.Dellliledidentificationofmaterialstobeinjected,includingadditives:.________-_____17.SurfaceOwner._________________________________(IfDifferentfromMineralOwner)(Attachadditionalsheetsasneeded)Addreu:______________________________________E-Mail-------------------------------18.U.S.G.S.Qu:tdrang.le:_________________________NameMapYear19.AOR<Art•ofRevlewlAttac:hmentstobelncludrdwllhaopll£1tlon:A.DAreaofReview(AOR)meansanarenwithinnotlessthanafixedmdiusofonc:-founh(1/4)milearoundaninjectionwellcalculatedtobeinaccordancewith40CFR146.06.TobeattachedtothisapplicationandidentifiedonasectionofUSGS7.5'TopographicMaponaminimumscaleofI"showingproposedinjectionwell(s)identifiedwithnY.mileradiuscircleidentifYingallproducingwells,injectionwells,w11terwellsanddryholeswithintheAOR.B.0Listofwellsinidentifiedbywelloperator,permitnumber,wellnameandnumberwithinAOR.C.BListofallSurfaceLandownersandaddresseswithinAOR.D.DescribecorrectivemeasuretoinsureUSDW's(UndergroundSourcesofDrinkingWater-Aquifm)an:protectedfrominjectionzoneinAOR.20.Ifncorporation,indicateSUiteofcorporution:--------..=-----==-------IscorporationregisteredwithKentuckySecretaryofState?0Yc:s0No21.IFAPRIVATEINDIVIDUAl.,SIGNATORYMUSTBESAMEORPROVIDEPOWEROFATTORNEYTOEXECUTEDOCUMENTS.WELLOPERATORASSUMESFINANCIALRESPONSIBILITYTOSECTION8OF805KAR1:110.SignatureofApplicantPrintorTypeNameofApplicantSworntoandsubscribedbeforemethis__dayof____,20_-NotaryPublicFORMED-14(8/07)TitleCOMMONWEALTHOFKENTUCKYDEPARTMENTFORNATURALRESOURCESDIVISIONOFOILANDGASwww.dogc:.ky.govP.0.Boll2244Frankfort,KY40601Phone;(502)573.0147Fox:(502)573·1099FOROmCIALUSEONLYBondNo:UICPermitNo.:OperatorNo.:ANNUALDISPOSALORINJECTIONWELLMONITORINGREPORTWELLACIIVITY0BrineDisposal0EnhancedRecovery0HydroaarhonStorageWellOwncr/Opcrntor:----------------------------PcnnanentAddrcss:______...,....-----------------------Strc:ctCity:._________State:____ZipCodc:____Phone:______Emnil:________________________________FnnnNnme:_____________WellNumlx'T:______County:.______Caner0FNL0FELCoordinates:_____._O_.FSL___....0_.FWLSEC__LTR__NO.__INJECTIONTOTALTUBING-CASINGANNULUSPRESSUREVOLUMEINJECTEDPRES.(OolloaalMoaltoria1)MonthYearAverageMulmumBBLS.MCFMinimumMaximumPSIGPSIGPSIGPSIGJan.Feb.MarchAprilMayJuneJulyAugustSept.Oct.Nov.Dec.CERTIFICATIONIcertlryunderthepenaltyorlawthatIhavepenonallyexaminedandamramiiiDrwiththelnrormatlonsubmittedInthisdocumentandallattachmentsandthaibasedonmyInquiryorthoselndlvldu11lsImmediatelyresponsiblerorobtainingthelnrormatlon,IbelievethatthelnrormallonIst111c,accurate,andcomplete.AuthorizedAgcnt=-----::-:---:..,.-------PrintNnmqSignature:.________________Title:___________Dale:____________SworntoDlldsubscribedbeforemethis__dayof____,20__NotaryPublicFORMED-18(8/07)OFKENTUCKYDEPARTMEl'ffFORNATURALRESOURCESDIVISIONOFOILANDGASwww.dogc.ky.govP.0.Box2244Frankfort,KY40601Phone:(502)573-0147Fwt:(502)573-1099FOROFFICIALUSEONLYBondNo:VICPermitNo.:No.:CERTIFICATIONOFMECHANICALINTEGRITY0NewWell0ExistingWellConvertedtoInjection0PeriodicTest(Requiredevery5yCIIrs)WellOwncr/OpCTDtor.-----------------------------PellllllncntStreetCi!y.._'-------Stnte:____ZipCode:----Phone:______Email=--------------------------------FarmWellNumber:County:______CanerOFNL0FELCoordinates:____.._O_,FSL____,_0_,FWLSEC__NO._WEIlCONSTRUCTIONIIi:..TotalDepth:lnjn:tlonlnterval(s):0WellboreSchematicAttachedTubingDepth:TubingSize:SizeorCasingTested:PackerDepth:PackerModel:0Cemenlffemp.!NoiseLag!!MECHANICAl.INTEGRITYPRESSURETEST(MIPT)MIPTtestatttlinimflmofJOOpsiforaminimIIIIIofJOmln11tesStartTime:EndTime:InjectionMedium:lnjedlonPressure:lnjec:tionPressure:0Gas(Nitrngennrapprovedgas)0WclllnjeetJngDuringTestCF.RTIFJCATIONAnnulusPressure:AnnulusPressure:lJLiquid0WellShut-InDuringTest.____________,herebycertifYKentuckyDivisionorOilandGaslamauthorizedtomakethisreportandthesubjectMITlnspeclor:._--::-:--:":"--------PrintNamewelltestwasperformedundermysupervisionanddirectionandthereferencedwellhasmechanicalintegri!yandsaidwell'spressuredidnotdeviatemoreSignature:____________than3%(+-)ofthetestpressureandallfactsstntedhereinoretrueandcorrect.Signature_____________Date:______________TitJe,_______________Date:Sworntoandsubscribedbeforeme:this__dayof____,20__NotnryPublicFORMED-22(8/07)COMMONWEALTHOFKENTUCKYDEPARTMENTFORNATURALRESOURCESDIVISIONOFOILANDGASwww.dogc.k.y.govP.0.Box2244Frankfort.KY40601Phone:1502)573-0147Fox:1502)573-1099CERTIFICATEOFCOMPLETIONFORANINJECTIONWELL1}PermitNo.------(Acopyofwelllocationplatmustbeattached}2}Operator(nameandaddress)----------------------3}LeaseName-----------------WellNo.-------0FNL0FEL4}CarterCoordinate____OFSL0FWLSec.__Ltr.__No.____5}County8evalionTotalDepth------6}Thecasingprogramfortheaboveidentifiedwellisasfollows:CasingSizeNeworUsedNo.orSacksCementCementColumn-ToptolloHom7)lnjechonshallbeaccomplishedthroughtub1ngandpackerasdescnbedbelow:SizeofTubingTypeofPackerPackerDepth8)WascementbondlogruniYES0NODIfyes.attachonecopy.9)Maximumanticipatedinjectionpressureatwellhead-------psi.I0)Maximumanticipatedinjectionvolume(bbls.)0(cu.ft.}0perday.II1Theinjectionzoneisknownasthe(geologicalname}________.andthisformationoccursinthewellfromto____12)a.Thesizecasinghasbeencementedtoadepthofandtheperforatedintervalisfromtowith__numberofperforations.b.Theinjectionintervalisthroughanopen-holeandparousstratabelowtheinjectionintervalhasnotbeendrilledorispluggedbockwithacolumnofcementfromto13}Describeindetailthemonitoringmethodfortheannulusbetweentheinjectiontubingandthenextstringofcasing.Identifythetypeofinstrumenttobeusedandthelimeintervalbetweenobservationsbyaresponsibleparty.RecordsofmonitoringmustbekeptonfilebytheoperatorandavanabletotheDivisionofOilandGasuponrequest.(Useadditionalpagesasneeded}.14)I.theoperatoroftheaboveIdentifiedwell,certifythattheaboveinformationisaccurateandcorrectandthatIfurthercertifythatthoverunthefollowingmechanicalintegritytest(s}oftheinstallationtoInsurethereorenoleaksinthesystem(Describeeachtestfully)(Useadditionalpagesasneeded)(Testpressuremustexceedthemaximumanticipatedinjectionpressurelistedonline9byatleastlOOpsi).Certifiedby_____________________(Operator'ssignatureonly)Date__________NameofSignee--------------------FORMED-23(REV.10/07}COMMONWEALTHOFKENTUCKYDEPARTMENTFORNATURALRESOURCESDMSIONOFOILANDGASwww.dogc.ky.govP.0.Box2244Frankfort.KY40601Phone:(502)573-0147Fox:(502)573-1099CERTIFICATEOFCOMPLETIONFORANINJECTIONWELLAHachmentforQuestion#13UsethisaHachmentsheettoprovidetheinformationforquestionnumber13:COMMONWEALTHOFKENTUCKYDEPARTMENTFORNATURALRESOURCESDIVISIONOFOILANDGASwww.dogc.ky.govP.0.Box2244Frankfort.KY40601Phone:(502)573-0147Fax:(502)573-1099CERTIFICATEOFCOMPLETIONFORANINJECTIONWELLAflachmentforQuestion#14UsethisaflachmentsheettoprovidetheInformationforquestionnumber14:COMMONWEALTHOFKENTUCKYDEPARTMENTFORNATURALRESOURCESDIVISIONOFOILANDGASwww.dogc.ky.govP.0.Box2244Frankfort,KY40602Phone:(5021573-0147Fax:(502)573-1099CasingandCemenlingPlanf01UICWellsper805KAR1:110WELLOPERATOR(APPLICANT),__CMUSTBE1NOENTICALTONAMEONBONDIMINERALOWNER(LESSOR),_____,,.,.-...,....------------=-=...,....----StreetCityCOUNTY___WELLNUMBER'---ELEVATION___FarmName:________WellNumber:County;OFELCarterCoordinates:OFNL____..O_.FSL____..Q_.FWLSEC__LTR__NO.__CASINGINFORMATIONTYPEODSIZEIWTIFTGRADENEWORUSEDDEPTHCEMENTINFORMATIONCASINGHOLESIZESACKSCLASSWEIGHTADDITIVESBLOW.OUTPREVENTERINFORMATIONBRANDTYPEWORKINGPRESSURETESTPRESSURESCHEMATICSHOWINGHOLESIZE&DEPTHOFEACHCASINGSTRINGICERTIFYTHATTHEABOVEINFORMATIONISTRUE,ACCURATEANDCOMPLETETOTHEBESTOFMYKNOWLEDGE.OPERATOR:DATETheDirectoroflheDivisionofOilandGas,DepartmentforNaturalResources,herebyapprovesofthisCasingandCemenUngPlanfortheabove-referencedlocaUon.DIRECTOR:.______________DATESIGNED:_______FORMED-25(10107)COMMONWEALTHOFKENTUCKYDEPARTMENTFORNATURALRESOURCESDIVISIONOFOILANDGAS1025CAPITALCENTERDR,STE201POSTOFFICEBOX2244FRANKFORTKY40601-2244PHONE:502·573-0147FAX;502-573-1099WWW.DOGC.KY.GOVOFFICEUSEONLYOPERATORNUMBER:-----------BONDNUMBER:-----------------TRANSFERFEE:Sl5.00/WELLTOTALNUMBEROFWELLSONTHISLEASETOBETRANSFERRED;TOTALAMOUNTREMI=TT=E=:D:-O"::"N:-:-::T::-:H::-:IS---FORM:TRANSFEROFCLASSII-VICWELLSPRESENTOPERATOR:TRANSFERREDTO:OPERATOR:----------------------------OPERATOR:ADDRESS:ADDRESS:PHONENO:TOTALNUMBEROFWELLSONTHISLEASETOBETRANSFERRED;-------------------------IFCORPORATION,NAMEOFPRINCIPALOFFICER:LEASENAME:COUNTY:WELLTesNUMBERXm!CARTERCOORDINATK'iFSL0FWLSEC.:_LTR:_No.:_FNL0FELFSL-r:::JFWLSEC.:LTR:NO.:0FNL0FEL----r::JFsL-r:::JFWLSEC.·LTR:NO.:=iFNL0FEL---FSL-r:::JFWLSEC.:_LTR:_No.:_FNL0FELFSL-r:::JFWLSEC.:LTR:NO.:FNL0FEL---FSL-r:::JFWLSEC.:LTR:NO.:0FNL0FEL----rJFsL-r:::JFWLSEC.:LTR:NO.:0FNL0FEL- - ----oFSL-r:::JFWLSEC,:_LTR:_No.·___0FNL0FELFSL-r:::JFWLSEC.:_LTR:_No.·_FNL0FELFSL-r:::JFWLSEC.:LTR.NO:0FNL0FEL- ---r:JFSL-r:::JFWLSEC.:_LTR._No·___0FNL__DFELUICPERMITNUMBERl\lethllnlcallnlegrilyPer(ormrdInlast5DDDDDDDDDDDATTEST:I,THEUNDERSIGNED,SUCCESSORINTITLETOTHEWELLSLISTEDABOVEORONTHEATTACHEDSHEETS,REQUESTTHEDIVISIONOFOILANDGAS,TOTRANSFERANDPLACETHESEWELLSUNDERMYBOND.THEREBY,IAMASSUMINGCOMPLETERESPONSIBILITYFORTHEMUNDERKRSCHAPTER353ANDTHERULESANDREGULATIONSPROMULGATEDTHEREUNDER.DATESIGNATUREOFPURCHASERTITLEPun:has"nssumc:sallresponsibilityfor!hewell(s)andprovidesfinancialresponsibilitypursuanttosection805KARI:II0,SIGNATUREOFSELLINGOPERATORTITLEINSTRUCTIONS:USEASEPARATEFORMFOREACHLEASE.ATTACHASEPARATELIST,IFTHEREAREMOREWELLSTHANCANBELISTEDONTHISSHEET.ENCLOSES25.00PERWELLTRANSFERFEE.MAKECHECKSPAYABLETO:KENTUCKYSTATETREA§URERFORMED-26(10/07)COMMONWEALTHOFKENTUCKYDEPARTMENTFORNATURALRESOURCESDIVISIONOFOILANDGASwww.dogc.ky.govAFFlOAVITTOANDIIANNUIOFI'UIOQINOAHOI'IWMOWEU.ASRECUIIWIBY805IWI1:.11QP.0.Box2244Frankfort,KY40602Phone:(502)573..0147Fax:(502)573-1099(TYPEORPRINTININK)IWoiENlt:JAllllfiESSOFlASTOPERATORE.&IAJI.ADORES!!OFlASTOPERATORE-toiAILAOORESSOfOAJGI-OPERATOR-ANDADDRESSOFc;(W.OPERATORE-MALAOORESSOFCCW.OPERATORPERMITNO._____ELEVATION___COONTY·-----[]FNL[]FEl.CARTfRCOORO.....TES___cFSl___cI'WLsec___TOTALCEPTM___AFFIDAVITlOBEMADEINTRlPUCATE.ONECOPYTOBEMALECTOTilEDIVISIONOFOILANDGAS.ONECOPYTOBERETAINEDBYTilETilETIIIIIOTOBEMAILEDBYREGISTfREOIU.LTOEACHCOALOPERATORN.UIEDATTIIEIRRESPECTIVEAOORESSES,AFFIDAVITSTATEOFI<EHT\JCKYCOUNTYOF________)SS:OFTHEABOVECAPTIONfOWELLDOESHEREBYSWEARTHATTHEPLUOOINOOFSAIDWASCOIIPLETEDACCORDINGTOINSTRUCTlOHSFRO..THE01.ANDGASINSPECTORANDACCOIIOINOTOCHAPTER353OFTHEKENTUCKYREVISEDSTATUTESDN______OFWHICHISUSTEDBELCPNORSHOWNONTHEIIACI<OFTHISFORM.(PLUGGEDCAlf)(8DTTOU)(TCf')(PLUOCESCRIPTION)FRO..o_______FROM_____FROMTOTOTOTOTOTOTOTOwwwwWTTHwW1TIIDICAftBID.OWllmANDINTZIIVALOFALLCASINOLUTINTHI!WELLMDIFMD-VII!ITWASIIIOTOFF:CASINOSIZE_____INTfRYAL_____SHOTOFFAT_____BOTTOioiOFCASIHOAT______CASINOSIZEINTERYAL________sHOTOFFAT______aonOMOFCASt<OAT_____________CASINOSIZEINTfRVAL_____sHOTOFFAT_____BOTTOMOFCASIHOAT_______FCASINOWASNOTLUTIITHI!WI!LL,INDICAnTHI!1101111!HIIUIIZIIMDIHTUIIIAL:CASINOSIZE--------CASINOSIZE---------INTfRYAL________IHTfRYAL________SIGNATUREOFCOHTRACTORRESI'ONSIBl£FORABOVEPlUGGING(REQUIRED)StGNATUft£OFCONTRACTORRESPONSIBlEFORMOVEPLUGGINGTrn.ESWOANTOANDSUBSIIII!fOBEFOAEMETHISDAlf_____DAYOF______CONTINUIDCEMENTTABLEHOLESIZE2"3"••S'6112"r1112"1314"10'12"16"HO.FT.FILJ.EDPERSACKOFCEMENT'-45'20'11'r4'2:114'2112'2113'2'1'112'"1CUBICFOOTPEASACkGIIAPHICAU.YSHIM'BELOWTHELOCATIONAND1NlERVALOFALLPLUGSiNSTALLED.SURFACE-CONTlNUED_------------------------------TOTAl.DEPTHIFntEWEU.ISTOBEL£FTAlAOOIIESTICWATERWBJ.,PLUGACCORIIINGTOTHE1HS1'ECTDR'SINSTRIJCTIONS.COMPUTEntiSF0J111ONBOntIIIE!AIIIIIIAV£TilEFOU.OWIIaAFADA\IIT!IIGN£D8YntEEITA'TC(JWijER.AffiDAVIT,E!TA'TCDNWIICIITIIISW!U.WASDRILLED.DE!IRtTIMTntEWEU.BEI.ErTCI'ENFROMntEfllattWATERZDNETO'TIIESURFACIFORUSEASAWATERWEllA110DOHERBIYACCEPI'ntEF\IUWPOIISIIIUTYFDRSAIDWIIlERWEll.TltE01.OPERATORR£IIAINS1IESI'OMSIIILEFORALLPLUGS1B.DWntEWATERZONE.SIGNAlUI£OFOY.NER00HISAGEHT