State: Zip Code: 

_____ _ Email:------

Fann Name: Well Number: _____ _ County: _____ _ 

Carter 0FNL 0FEL 

Coordinatc:s: n FSL ___ _..O_.FWL SEC __ LTR __ NO. __ 

Date Re-work Commenced:. ___ _ D11tc Re-work Completed:. ___ _ 

WEI . L CASING . RECORD - BEFORE RE -WORK 

ACID OR FRACTURE 

CASING CEMENT PERFORATIONS TREATMENT RECORDS 

Size Depth Sacks Type From To 

WELL CASING RECORD - AFTER RE -WORK (Indicate Additions or Changes Onf.J") 

ACID OR FRACTURE 

CASING CEMENT PERFORATIONS TREATMENT RECORDS 

Size Denth S11cks Tvne From To 

GEOPHYSICAL LOGS RAN LOGGED INTERVALS 

CERTIFICATION 

I certify under the penalty of law that I hne personally enmlned and am f•mlllar with the Information 

submitted In this document and all attachments and that based on my Inquiry of those Individuals 

Immediately responsible for obtaining the Information, I believe that the Information Is true, accurate, and 

complete. Authorized Agent: Title:. ___________ _ 

Print Name: 

Signature:. _______________ _ Date:. ________ _ 

Sworn to and before: me: this __ day of ___ _. 20 __ 

Notary Public 

FORM ED-4 (8107) 
3. Well Owner/Operator: -----------------------------

4. _________ Stm:t City 

5. State;---- Zip Code:---- Phone;. ______ _ Email:----------

6. Mineral Owner (Lessor):---------------- Well Number: ------

7. Street City Zip Phone 

0FNL 0FEL 

County 

Caner 

8. Coordinates: ___ _..O_,FSL ___ _..O_,FWL SEC. __ LTR. __ NO. __ 

9. Approximate depth of Underground Source of Drinking Water (USDW): ______ _. measures to insure 

protection of USDW from injection operations IIJ'C to be detailed (sec question 19. section D). 

10. Name of Field: ------------· 

II . Name of Geologie Injection zone: Depth: Top ___ Bottom __ . 

12. Proposed Tollll Depth: if existing well; to depth of _____ _ 

13. Injection method: D Through Perforations D Packer on Tubing Assembly 

14. If packer on tubing nssembly is used, depth packer is set: not to exceed fifty (50) feel above 

injection zone. 

I 5. Estimated formation breakdown pressure::. ____ psi g. 

16. Dellliled identification of materials to be injected, including additives:. ________ - _ _ __ _ 

17. SurfaceOwner. ______________________________ ___ 

(If Different from Mineral Owner) (Attach additional sheets as needed) 

Addreu: ____________________________________ __ 

E-Mail -------------------------------

18. U.S.G.S. Qu:tdrang.le: ________________________ _ 

Name Map Year 

19. AOR <Art• ofRevlewl Attac:hments to be lncludrd wllh aopll£1tlon: 

A. D Area of Review (AOR) means an aren within not less than a fixed mdius ofonc:-founh (1/4) mile around an 

injection well calculated to be in accordance with 40 CFR 146.06. To be attached to this application and 

identified on a section of USGS 7.5' Topographic Map on a minimum scale of I" showing proposed 

injection well(s) identified with n Y. mile radius circle identifYing all producing wells, injection wells, w11ter 

wells and dry holes within the AOR. 

B. 0 List of wells in identified by well operator, permit number, well name and number within AOR. 

C. B List of all Surface Landowners and addresses within AOR. 

D. Describe corrective measure to insure USDW's (Underground Sources of Drinking Water-Aquifm) 

an: protected from injection zone in AOR. 

20. If n corporation, indicate SUite of corporution: --------..=-----==-------

Is corporation registered with Kentucky Secretary of State? 0 Y c:s 0 No 

21 . IF A PRIVATE INDIVIDUAl., SIGNATORY MUST BE SAME OR PROVIDE POWER OF 

ATTORNEY TO EXECUTE DOCUMENTS. WELL OPERATOR ASSUMES FINANCIAL 

RESPONSIBILITY TO SECTION 8 OF 805 KAR 1:110. 

Signature of Applicant 

Print or Type Name of Applicant 

Sworn to and subscribed before me this __ day of ___ _, 20_-

Notary Public 

FORM ED-14(8/07) 

Title 
p

y 

y

g

Well Owncr/Opcrntor: ----------------------------

Pcnnanent Addrcss: 

______ ...,....

-----------------------

Strc:ct City:. ________ _ State: ___ _ ZipCodc: ___ _ Phone: _____ _ 

Emnil: _______________________________ _ 

Fnnn Nnme: _____________ Well Numlx'T: ______ County:. _____ _ 

Caner 0 FNL 0 FEL 

Coordinates: ___ __._O_.FSL ___ .... 0_.FWL SEC __ LTR __ NO. __ 

INJECTION TOTAL TUBING-CASING ANNULUS 

PRESSURE VOLUME INJECTED PRES. (Oolloaal Moaltoria1) 

Month Year Average Mulmum BBLS. MCF Minimum Maximum 

PSIG PSIG PSIG PSIG 

Jan. 

Feb. March 

April 

May 

June July 

August 

Sept. 

Oct. 

Nov. 

Dec. 

CERTIFICATION 

I certlry under the penalty or law that I have penonally examined and am ramiiiDr with the lnrormatlon 

submitted In this document and all attachments and thai based on my Inquiry or those lndlvldu11ls 

Immediately responsible ror obtaining the lnrormatlon, I believe that the lnrormallon Is t111c, accurate, and 

complete. 

Authorized Agcnt=-----::-:---:..,.-------

PrintNnmq Signature:. _______________ _ 

Title: __________ _ 

Dale: ___________ _ 

Sworn to Dlld subscribed before me this __ day of ____ , 20 __ 

Notary Public 

FORM ED- 18 (8/07) 
Well Owncr/OpCTDtor. -----------------------------Pellllllncnt 

Street 

Ci!y.._' ------- Stnte: ___ _ Zip Code:---- Phone: _____ _ 

Email=--------------------------------

Farm Well Number: County: _____ _ 

Caner OFNL 0FEL 

Coordinates: ___ _.._O_,FSL ___ _,_0_,FWL SEC __ NO._ 

WEI l CONSTRUCTION IIi: .. 

Total Depth: lnjn:tlon lnterval(s): 0 Wellbore Schematic Attached Tubing Depth: Tubing Size: Size or Casing Tested: 

Packer Depth: Packer Model: 0 Cemenlffemp.!Noise Lag!! 

MECHANICAl. INTEGRITY PRESSURE TEST (MIPT) 

MIPT test at ttlinimflm of JOO psi for a minim IIIII of JO mln11tes 

Start Time: 

End Time: 

Injection Medium: 

lnjedlon Pressure: lnjec:tion Pressure: 

0 Gas (Nitrngen nr approved gas) 

0 WclllnjeetJng During Test 

CF.RTIFJCA TION 

Annulus Pressure: Annulus Pressure: 

lJ Liquid 

0 Well Shut-In During Test 

._ ___________ ,hereby certifY Kentucky Division or Oil and Gas 

lam authorized to make this report and the subject MIT lnspeclor:._--::-:--:":"--------

Print Name 

well test was performed under my supervision and 

direction and the referenced well has mechanical 

integri!y and said well's pressure did not deviate more Signature: ___________ _ 

than 3% (+-) of the test pressure and all facts stnted 

herein ore true and correct. 

Signature ____________ _ Date: _____________ _ 

TitJe, ______________ _ 

Date: 

Sworn to and subscribed before me: this __ day of ___ _, 20 __ 

Notnry Public 

FORM ED-22 (8/07) 
2} Operator(name and address) ----------------------

3} Lease Name ----------------- Well No. -------

0 FNL 0 FEL 

4} CarterCoordinate ____ OFSL 0 FWL Sec. __ Ltr. __ No. ___ _ 

5} County 8evalion Total Depth------

6} The casing program for the above identified well is as follows: 

Casing Size New or Used No. or Sacks Cement Cement Column-Top to lloHom 

7) lnjechon shall be accomplished through tub1ng and packer as descnbed below: 

Size of Tubing Type of Packer Packer Depth 

8) Was c ement bond log runi YES 0 NOD If yes. attach one copy. 9) Maximum anticipated injection pressure at wellhead-------psi. 

I 0) Maximum anticipated injection volume (bbls.) 0 (cu.ft.} 0 per day. 

I I 1 The injection zone is known as the (geological name} _______ _. and this formation 

occurs in the well from to ___ _ 

12) a. The size casing has been cemented to a depth of and the 

perforated interval is from to with __ number of perforations. 

b. The injection interval is through an open-hole and parous strata below the injection interval 

has not been drilled or is plugged bock with a column of cement from to 

13} Describe in detail the monitoring method for the annulus between the injection tubing and the 

next string of casing. Identify the type of instrument to be used and the lime interval between 

observations by a responsible party. Records of monitoring must be kept on file by the operator 

and avanable to the Division of Oil and Gas upon request. (Use additional pages 

as needed}. 

14) I. the operator of the above Identified well, certify that the above information is accurate and correct and that I further 

certify that t hove run the following mechanical integrity test(s} of the installation to Insure there ore no leaks in the 

system (Describe each test fully) (Use additional pages as needed) (Test pressure must exceed the maximum 

anticipated injection pressure listed on line 9 by atleastlOO psi). 

Certified by _____________________ (Operator's signature only) 

Date __________ Name of Signee--------------------

FORM ED-23 (REV. 10/07} 
COMMONWEALTH OF KENTUCKY 

DEPARTMENT FOR NATURAL RESOURCES 

DM SION OF OIL AND GAS 

www.dogc.ky.gov 

P. 0. Box 2244 

Frankfort. KY 40601 

Phone: (502) 573-0147 Fox: (502) 573-1099 

CERTIFICATE OF COMPLETION FOR AN INJECTION WELL 

AHachment for Question #13 

Use this aHachment sheet to provide the information for question number 13: 
Use t

s a

ac

e

t s

eet to p

o

de t

e 

o

at

o

o

quest

o

u

be
Farm Name: _______ _ Well Number: County; 

Carter OFEL Coordinates: 

OFNL 

___ _..O_.FSL ___ _..Q_.FWL SEC __ LTR __ NO. __ 

CASING INFORMATION 

TYPE OD SIZE I WTIFT GRADE NEW OR USED DEPTH 

CEMENT INFORMATION 

CASING HOLE SIZE SACKS CLASS WEIGHT ADDITIVES 

BLOW.OUT PREVENTER INFORMATION 

BRAND TYPE WORKING PRESSURE TEST PRESSURE 

SCHEMATIC SHOWING HOLE SIZE & DEPTH OF EACH CASING STRING 

I CERTIFY THAT THE ABOVE INFORMATION IS TRUE, ACCURATE AND COMPLETE TO THE BEST 

OF MY KNOWLEDGE. 

OPERATOR: DATE 

The Director of lhe Division of Oil and Gas, Department for Natural Resources, hereby approves of this 

Casing and CemenUng Plan for the above-referenced locaUon. 

DIRECTOR:.__ ___________ _ DATE SIGNED: ______ _ FORM ED-25 (1 0107) 
PHONE NO: 

TOTAL NUMBER OF WELLS ON THIS LEASE TO BE 

TRANSFERRED; -------------------------

IF CORPORATION, NAME OF PRINCIPAL OFFICER: 

LEASE NAME: COUNTY: 

WELL 

Tes 

NUMBER 

Xm! 

CARTER 

COORDINATK'i 

FSL 0FWL 

SEC.:_LTR:_No.:_ FNL 0 FEL 

FSL -r:::JFWL 

SEC.: LTR: NO.: 0FNL 0FEL 

- - - -r::JFsL -r:::JFWL 

SEC.· LTR: NO.: =iFNL 0FEL 

- - - FSL -r:::JFWL 

SEC.:_LTR:_No.:_ FNL 0 FEL 

FSL -r:::JFWL 

SEC.: LTR: NO.: FNL 0 FEL 

- - - FSL -r:::JFWL 

SEC.: LTR: NO.: 0FNL 0FEL 

- - - -rJFsL -r:::JFWL 

SEC.: LTR: NO.: 0FNL 0FEL 

- - - ---oFSL -r:::J FWL 

SEC,:_LTR:_ No.· _ __ 0FNL 0FEL 

FSL -r:::JFWL 

SEC.:_LTR:_ No.·_ FNL 0 FEL 

FSL -r:::JFWL 

SEC.: LTR. NO: 0FNL 0FEL 

- - --r:JFSL -r:::JFWL 

SEC.:_LTR._No · _ __ 0FNL __ DFEL 

UIC 

PERMIT NUMBER 

l\lethllnlcal lnlegrily 

Per(ormrd In last 5 

D D D D D D D D D D D 

ATTEST: I, THE UNDERSIGNED, SUCCESSOR IN TITLE TO THE WELLS LISTED ABOVE OR ON THE ATTACHED 

SHEETS, REQUEST THE DIVISION OF OIL AND GAS, TO TRANSFER AND PLACE THESE WELLS UNDER MY BOND. 

THEREBY, I AM ASSUMING COMPLETE RESPONSIBILITY FOR THEM UNDER KRS CHAPTER 353 AND THE RULES 

AND REGULATIONS PROMULGATED THEREUNDER. 

DATE SIGNATURE OF PURCHASER TITLE 

Pun: has" nssumc:s all responsibility for !he well(s) and provides financial responsibility pursuant to section 805 KAR I : II 0, 

SIGNATURE OF SELLING OPERATOR TITLE 

INSTRUCTIONS: USE A SEPARATE FORM FOR EACH LEASE. ATTACH A SEPARATE LIST, IF THERE ARE MORE 

WELLS THAN CAN BE LISTED ON THIS SHEET. ENCLOSE S25.00 PER WELL TRANSFER FEE. 

MAKE CHECKS PAYABLE TO: KENTUCKY STATE TREA§URER 

FORM ED-26 (10/07) 
E-toiAIL AOORESS Of OAJGI- OPERATOR 

-AND ADDRESS OF c;(W. OPERATOR E-MAL AOORESS OF CCW. OPERATOR PERMIT NO. ____ _ ELEVATION __ _ COONTY·-----

CARTfR [] FNL [] FEl. 

COORO ..... TES ___ c FSl ___ c I'WL sec __ _ 

TOTAL CEPTM __ _ 

AFFIDAVIT lOBE MADE IN TRlPUCATE. ONE COPY TO BE MALEC TO TilE DIVISION OF OIL AND GAS. ONE COPY TOBE RETAINED BY TilE 

TilE TIIIIIO TO BE MAILED BY REGISTfREO IU.L TO EACH COAL OPERATOR N.UIED AT TIIEIR RESPECTIVE AOORESSES, 

AFFIDAVIT 

STATE OF I<EHT\JCKY 

COUNTYOF ________ )SS: 

OF THE ABOVE CAPTIONfO WELL DOES HEREBY SWEAR THAT THE PLUOOINO OF SAID 

WAS COIIPLETED ACCORDING TO INSTRUCTlOHS FRO.. THE 01. AND GAS INSPECTOR AND ACCOIIOINO TO CHAPTER 353 OF THE KENTUCKY REVISED 

STATUTES DN ______ OF WHICH IS USTED BELCPN OR SHOWN ON THE IIACI< OF THIS FORM. 

(PLUGGED CAlf) 

(8DTTOU) (TCf') (PLUO CESCRIPTION) 

FRO..o_ ___ ___ FROM ____ _ FROM 

TO 

TO 

TO TO 

TO 

TO 

TO TO 

w w w w 

WTTH 

w 

W1T 

IIDICAft BID.OW llmANDINTZIIVAL OF ALL CASINO LUT IN THI! WELL MD IF MD-VII! IT WAS IIIOTOFF: 

CASINO SIZE _____ INTfRYAL _____ SHOT OFF AT _____ BOTTOioiOF CASIHOAT _____ _ 

CASINOSIZE INTERYAL ________ sHOTOFFAT ______ aonOMOFCASt<OAT ___________ __ 

CASINOSIZE INTfRVAL _____ sHOTOFFAT _____ BOTTOMOFCASIHOAT ______ _ 

F CASINO WAS NOT LUT II THI! WI!LL, INDICAn THI! 1101111! HIIU IIZII MD IHTUIIIAL: 

CASINO SIZE--------

CASINO SIZE---------

INTfRYAL _______ _ IHTfRYAL 

_______ _ 

SIGNATURE OF COHTRACTOR RESI'ONSIBl£ FOR ABOVE PlUGGING 

(REQUIRED) StGNA TUft£ OF CONTRACTOR RESPONSIBlE FOR MOVE PLUGGING Trn.E 

SWOANTOANDSUBSIIII!fOBEFOAEMETHISDAlf _____ DAYOF ______ 

CONTINUID 
CEMENT TABLE 

HOLE SIZE 2" 3" •• S' 6112" r 1112" 1314" 10' 12" 16" 

HO. FT. FILJ.ED PER 

SACK OF CEMENT' -45' 20' 11' r 4' 2:114' 2112' 2113' 2' 1' 112' 

"1 CUBIC FOOT PEA SACk 

GIIAPHICAU. Y SHIM' BELOW THE LOCATION AND 1NlERVAL OF ALL PLUGS iNSTALLED. 

SURFACE- CONTlNUED _ 

- -- -

- -

- -

- -

- -- -- -

- -

- -- -- -

- -

- -- - TOTAl. DEPTH 

IF ntEWEU.IS TO BEL£FT AlA OOIIESTIC WATERWBJ., PLUG ACCORIIING TO THE 1HS1'ECTDR'S INSTRIJCTIONS. COMPUTE ntiS F0J111 ON 

BOnt IIIE! AIIIIIIAV£ TilE FOU.OWIIa AFADA\IIT !IIGN£D 8Y ntE EITA'TC (JWijER. 

AffiDAVIT