KANSAS CORPORATION COMMISSION

OIL & GAS CONSERVATION DIVISION

WELL COMPLETION FORM

WELL HISTORY - DESCRIPTION OF WELL & LEASE

Form ACO-1

July 2014

Form must be Typed

Form must be Signed

All blanks must be Filled

OPERATOR: License #

Name:

Address 1: 

Address 2:

City: State: Zip: +

Contact Person:

Phone: ( )

CONTRACTOR: License #

Name:

Wellsite Geologist:

Purchaser:

Designate Type of Completion:

 New Well Re-Entry Workover

Oil WSW SWD SIOW

Gas D&A ENHR SIGW

OG GSW Temp. Abd. 

CM (Coal Bed Methane) 

Cathodic Other (Core, Expl., etc.): 

If Workover/Re-entry: Old Well Info as follows:

Operator:

Well Name:

Original Comp. Date: Original Total Depth:

 Deepening Re-perf. Conv. to ENHR Conv. to SWD

 Plug Back Conv. to GSW Conv. to Producer

 Commingled Permit #:

 Dual Completion Permit #:

 SWD Permit #:

 ENHR Permit #:

 GSW Permit #:

Spud Date or Date Reached TD Completion Date or

INSTRUCTIONS: The original form shall be filed with the Kansas Corporation Commission, 130 S. Market - Room 2078, Wichita, Kansas 67202, within 120 

days of the spud date, recompletion, workover or conversion of a well. If confidentiality is requested and approved, side two of this form will be held confidential for a period of 2 years. Rules 82-3-130, 82-3-106 and 82-3-107 apply. Drill Stem Test, Cement Tickets and Geological Well Report must be attached.

API No. 15 -

Spot Description:

- - - Sec. Twp. S. R. East West

 Feet from North / South Line of Section

 Feet from East / West Line of Section

Footages Calculated from Nearest Outside Section Corner:

 NE NW SE SW

GPS Location: Lat: , Long: 

Datum: NAD27 NAD83 WGS84

County:

Lease Name: Well #:

Field Name:

Producing Formation:

Elevation: Ground: Kelly Bushing:

Total Vertical Depth: Plug Back Total Depth:

Amount of Surface Pipe Set and Cemented at: Feet

Multiple Stage Cementing Collar Used? Yes No

If yes, show depth set: Feet

If Alternate II completion, cement circulated from:

feet depth to: w/ sx cmt.

Drilling Fluid Management Plan

(Data must be collected from the Reserve Pit)

Chloride content: ppm Fluid volume: bbls

Dewatering method used:

Location of fluid disposal if hauled offsite:

Operator Name:

Lease Name: License #:

Quarter Sec. Twp. S. R. East West

County: Permit #:

KCC Office Use ONLY

 Confidentiality Requested

 Date:

Confidential Release Date:

Wireline Log Received

Geologist Report Received

 UIC Distribution

 ALT I II III Approved by: Date:

AFFIDAVIT

I am the affiant and I hereby certify that all requirements of the statutes, rules and 

regulations promulgated to regulate the oil and gas industry have been fully complied 

with and the statements herein are complete and correct to the best of my knowledge.

Signature:

Title: Date:

Recompletion Date Recompletion Date

Confidentiality Requested:

 Yes No

(e.g. xx.xxxxx) (e.g. -xxx.xxxxx)
Operator Name: Lease Name: Well #:

Sec. Twp. S. R. East West County:

INSTRUCTIONS: Show important tops of formations penetrated. Detail all cores. Report all final copies of drill stems tests giving interval tested, time tool 

open and closed, flowing and shut-in pressures, whether shut-in pressure reached static level, hydrostatic pressures, bottom hole temperature, fluid recovery, 

and flow rates if gas to surface test, along with final chart(s). Attach extra sheet if more space is needed. 

Final Radioactivity Log, Final Logs run to obtain Geophysical Data and Final Electric Logs must be emailed to kcc-well-logs@kcc.ks.gov. Digital electronic log 

files must be submitted in LAS version 2.0 or newer AND an image file (TIFF or PDF).

Page Two

Drill Stem Tests Taken Yes No

(Attach Additional Sheets)

Samples Sent to Geological Survey Yes No

Cores Taken Yes No

Electric Log Run Yes No

List All E. Logs Run:

 Log Formation (Top), Depth and Datum Sample

Name Top Datum

CASING RECORD New Used

Report all strings set-conductor, surface, intermediate, production, etc.

Purpose of String Size Hole

Drilled

Size Casing

Set (In O.D.)

Weight

Lbs. / Ft.

Setting

Depth

Type of 

Cement

# Sacks

Used

Type and Percent

Additives

ADDITIONAL CEMENTING / SQUEEZE RECORD

Purpose:

Perforate

Protect Casing

Plug Back TD

Plug Off Zone

Depth

Top Bottom Type of Cement # Sacks Used Type and Percent Additives

Shots Per Foot PERFORATION RECORD - Bridge Plugs Set/Type

Specify Footage of Each Interval Perforated

Acid, Fracture, Shot, Cement Squeeze Record

(Amount and Kind of Material Used) Depth

TUBING RECORD: Size: Set At: Packer At: Liner Run:

Yes No

Date of First, Resumed Production, SWD or ENHR. Producing Method:

Flowing Pumping Gas Lift Other (Explain)

Estimated Production

Per 24 Hours

Oil Bbls. Gas Mcf Gas-Oil Ratio Gravity

DISPOSITION OF GAS: METHOD OF COMPLETION: PRODUCTION INTERVAL:

Vented Sold Used on Lease

(If vented, Submit ACO-18.)

Open Hole Perf. Dually Comp.

(Submit ACO-5)

Commingled

(Submit ACO-4)

Other (Specify)

Water Bbls. 

Mail to: KCC - Conservation Division, 266 N Main St, Ste 220, Wichita, KS 67202-1513

Did you perform a hydraulic fracturing treatment on this well? Yes No (If No, skip questions 2 and 3)

Does the volume of the total base fluid of the hydraulic fracturing treatment exceed 350,000 gallons? Yes No (If No, skip question 3)

Was the hydraulic fracturing treatment information submitted to the chemical disclosure registry? Yes No (If No, fill out Page Three of the ACO-1)
* Total Water Volume sources may include fresh water, produced water, and/or recycled water. ** Information is based on the maximum potential for concentration and thus the total may be over 100%.

Ingredient information for chemicals subject to 29 CFR 1910.1200(i) and Appendix D are obtained from suppliers Material Safety Data Sheets (MSDS).

HYDRAULIC FRACTURING FLUID PRODUCT COMPONENT INFORMATION DISCLOSURE

Last Fracture Date: County: API Number:

Operator Name: Well Name and Number:

Latitude: Longitude: Datum:

Production Type: True Vertical Depth (TVD): Total Base Fluid Volume (gal)*:

Page Three

 Trade Name Supplier Purpose Ingredients Chemical Abstract

Service Number (CAS #)

Maximum Ingredient Concentration

in Additive (% by mass)**

Maximum Ingredient Concentration

in HF Fluid (% by mass)**

Authorized Representative’s 

Name, Address, and Phone Number

Hydraulic Fracturing Fluid Composition:

Ingredients shown above are subject to 29 CRF 1910.1200(i) and appear on Material Safety Data Sheets (MSDS). Ingredients shown below are Non-MSDS.
KANSAS CORPORATION COMMISSION

OIL & GAS CONSERVATION DIVISION

WELL COMPLETION (FORM ACO-1)

Instructions

Form ACO-1 Instructions

July 2014

General Instructions.

1. The form must be typed.

2. All horizontal wellbore completions are required to attach the 

additional information with their ACO-1 as listed below in Section 11.

Section 0: Confidentiality.

 0a. Confidentiality Requested. Mark the box to indicate if 

confidentiality is requested.

Section 1: Operator/Well Information. 

1a. License #. Enter the operator’s license number.

1b. Name. Enter the operator’s full name as it appears on the operator’s 

 license.

1c. Address. Enter the operator’s mailing address (street or PO Box).

1d. City/State/Zip. Enter the operator’s city, state, and zip code.

1e. Contact Person. Enter the name of the individual who will be 

the operator’s contact person, should Conservation Staff need to 

contact the operator about the Form. The contact person may be the 

operator or the operator’s agent.

1f. Phone. Enter the phone number of the contact person listed in “1e” 

 above.

1g. Contractor License #. Enter the Drilling Contractor’s license 

number. The drilling contractor may be the operator or the operator’s 

 agent.

1h. Contractor Name. Enter the name of the drilling contractor as it 

appears on the drilling contractor’s operator license.

1i. Wellsite Geologist. Enter the name of the wellsite geologist 

 witnessing the completion work.

1j. Purchaser. Enter the name of the purchaser of the oil and/or gas 

produced from the subject well.

1k. Designate Type of Completion. Mark the appropriate box to 

indicate if it is a new well, re-entry, or workover. Also mark the 

appropriate box(es) to indicate the type of completion. Multiple 

boxes may be marked.

1L. Old Well Information. Only complete this section if the subject

well is a workover or reentry.

 1l(1). Operator. Enter the name of the last operator of the subject 

wellbore, prior to workover or re-entry operations.

 1l(2). Well Name. Enter the name under which the subject well was 

last operated.

 1l(3). Original Completion Date. Enter the date on which the 

subject well was originally completed.

 1l(4). Original Total Depth. Enter the original total depth of the 

subject well.

 1l(5). Deepening, Re-perforate, Convert to Enhanced Recovery/

Saltwater Disposal/Gas Storage. Mark the appropriate 

box(es) to indicate whether, through workover/re-entry 

operations, the well has been deepened, re-perforated, 

and/or converted to an enhanced recovery or saltwater 

disposal well. Multiple boxes may be marked. For each box 

that is marked, enter the corresponding permit number to the 

right of the box.

1m. Spud Date or Recompletion Date. For new wells, enter the date 

on which the well was spud. Otherwise, enter the date on which 

current recompletion operations were commenced.

1n. Date Reached TD. Enter the date on which the operator reached 

 total depth.

1o. Completion Date or Recompletion Date. For new wells, enter the 

date on which the new well was completed. Otherwise, enter the 

date on which current recompletion operations were finished.

1p. API No. Enter the API Number. This number is subject to change. 

Staff will contact the operator if major changes are made to the 

subject well’s API Number.

1q. Spot Location. Enter the geographic location of the subject well by 

1⁄4 1⁄4 1⁄4 1⁄4, Section, Township, and Range. Mark the appropriate box 

to indicate if the range is east or west of the Sixth Principal Meridian.

1r. Footage Location from Section Lines.

1r(1). Enter the number of feet the subject well is located from 

the South or North section line. Circle which section line the 

measurement was taken from.

1r(2). Enter the number of feet the subject well is located from 

the East or West section line. Circle which section line the 

measurement was taken from.

1s. Footages Calculated From Nearest Outside Section Corner. 

 Mark the appropriate box indicating the outside section corner 

nearest the location of the well.

1s(1). Enter GPS latitude

1s(2). Enter GPS Longitude

1s(3). Enter Datum

1t. County. Enter the county in which the well is located.

1u. Lease Name/Well Number. Enter the name of the lease and the 

 well number.

1v. Field Name. List the name of the field where the well is located. Field 

names are available from KGS at http://www.kgs.ku.edu/Magellan/

Field/index.html, or Independent Oil & Gas Service at http://www.

 iogsi.com.

1w. Producing Formation. Enter the name of the geologic formation 

from which the well is producing.

1x. Elevation.

 1x(1). Ground. Enter the elevation in feet above sea level for the 

well’s location.

 1x(2). Kelly Bushing. Enter the elevation in feet above sea level of 

the Kelly bushing during drilling operations.

1y. Total Vertical Depth. Enter the total vertical depth of the well.

1z. Plug Back Total Depth. Enter the total depth of the plug back in the 

 well.

1aa. Amount of Surface Pipe Set and Cemented. Enter the depth to 

which surface pipe is set and cemented.

1bb. Multiple Stage Cementing Collar Used.

1bb(1). Mark the box to show if a multiple stage cementing collar 

 was used to complete/recomplete the well.

1bb(2). If a multiple stage cementing collar was used, fill in the blank 

 with the depth at which it was set.

1cc. Alternate II Completion. If the subject well is an Alternate II

Completion, enter the depth to which cement was circulated and the 

number of sacks of cement used.

Section 2: Drilling Fluid Management Plan.

2a. Chloride Content. Enter the chloride content in parts per million of 

 reserve pit fluids.

2b. Fluid Volume. Enter the volume in barrels of reserve pit fluids used.

2c. Dewatering Method Used. Enter the dewatering method used at 

the well during drilling operations.

2d. Location of Fluid Disposal if Hauled Offsite. 

 2d(1). Operator Name. Enter the name of the operator who 

disposed of the drilling fluids.

 2d(2). Lease Name. Enter the name of the lease at which the 

drilling fluids were disposed.

 2d(3). License Number. Enter the license number of the operator 

who disposed of the drilling fluids.

 2d(4). Geographic Location. Enter the geographic location of the 

lease on which drilling fluids were disposed by 1⁄4, Section, 

Township, and Range. Mark the box to indicate if the Range is 

East or West of the Sixth Principal Meridian.

 2d(5). County. Enter the county in which the fluid disposal is 

located.

 2d(6). Permit Number. If the fluid will be hauled offsite and injected 

into an enhanced recovery or disposal well, enter the permit 

number under which the operator is authorized to conduct 

injection operations into the well.

Section 3: Verification. 

3a. Signature. The operator or the operator’s agent must sign the Well 

 Completion Form.

3b. Title. The title, with respect to the operator, of the individual signing 

 the form.

3c. Date. Enter the date on which the form is completed.
Kansas Corporation Commission | oil & Gas Conservation Division

Form ACO-1 Instructions | Page 2 

July 2014

Section 4: Operator and Well Information.

4a. Operator Name. Enter the operator’s full name as it appears on the 

 operator’s license.

4b. Lease Name/Well Number. Enter the lease name and well number 

for the well.

4c. Geographic Location. Enter the location of the well by Section,

Township, and Range, and mark the box to indicate if the Range is 

East or West of the Sixth Principal Meridian.

4d. County. Enter the name of the county in which the well is located.

Section 5: Logs, Samples, and Test Reporting.

5a. Drill Stem Tests. Mark the box to indicate whether drill stem tests 

were taken. If drill stem tests were taken, additional sheets must be 

attached to the ACO-1.

5b. Samples Sent to Geological Survey. Mark the box to indicate if 

geologic samples were sent to KGS.

5c. Cores Taken. Mark the box to indicate if cores were taken.

5d. Electric Log Run. Mark the box to indicate if electric log(s) were run 

on the subject well.

5e. List All Electric Logs Run. If electric logs were run on the subject 

well, list all of the electric logs conducted.

5f. Formation (Top), Depth, and Datum. Mark the appropriate “Log” 

or “Sample” box, or both boxes, to indicate whether the formation 

information is derived from a driller’s log or geologic samples. 

Enter the name of each penetrated producing or storage formation, 

the formation top, and the datum of the formation top. The formation 

datum is the distance from the formation top to the mean sea level. It 

may be a positive or a negative number.

Section 6: Casing Record.

6a. New or Used. Mark the box to indicate if the well’s casing is new or 

had been previously used.

6b. Casing Strings Used. For each separate string of casing used, 

enter the following information:

 6b(1). Purpose of String. The purpose of the casing string.

 6b(2). Size Hole Drilled. The size of hole drilled for the casing 

string.

 6b(3). Size Casing Set. The outside diameter of the casing.

 6b(4). Weight. The weight of the casing set, expressed in pounds 

per foot.

 6b(5). Setting Depth. The depth to which the casing string is set.

 6b(6). Type of Cement. The type of cement used to set the casing 

string.

 6b(7). # Sacks Used. The number of sacks of cement used to set 

the casing string.

 6b(8). Type and Percent Additives. The type and percent additives 

to the cement used to set the casing string.

Section 7: Additional Cementing/Squeeze Record.

7a. Purpose. Mark the blank(s) indicating the purpose of the additional 

cementing/squeeze. Mark all that apply.

7b. Depth Top Bottom. Enter the depth of the additional cementing from 

top to bottom.

7c. Type of Cement. Enter the type of cement used for the additional 

 cementing.

7d. Number of Sacks Used. Enter the number of sacks used for the 

 additional cementing.

7e. Type and Percent Additives. Enter the type and percent of 

additives to the additional cementing.

7f. Three Hydraulic Fracturing Questions. Mark the appropriate box 

for each question.

Section 8: Perforation, Acid, Fracture, Shot, and Cement Squeeze Record.

For each set of perforations in the well, enter the following information:

8a. Shots per foot. Enter the number of perforations per foot.

8b. Perforation Record - Bridge Plugs Set/Type & Specific Footage 

of Each Interval Perforated. Enter the type of bridge plugs, the 

depth the bridge plugs are set for each interval perforated, and the 

depth of each perforated interval.

8c. Acid, Fracture, Shot, Cement Squeeze Record. Enter the amount 

and kind of material used for any acid, fracture, or shot treatment, 

and any cement squeeze at each perforation interval.

8d. Depth. Enter the depth of the acid, fracture, shot, or cement squeeze 

at each perforation interval.

Section 9: Miscellaneous.

9a. Tubing Record.

 9a(1). Size. Enter the size of tubing set in the subject well.

 9a(2). Set at. Enter the depth at which the tubing is set in the 

subject well.

 9a(3). Packer at. Enter the depth at which the tubing packer is set in 

the subject well.

9b. Liner Run. Mark the appropriate box to indicate if a liner is in the 

 subject well.

9c. Date of First or Resumed Production, SWD, or ENHR. For newly 

completed wells, enter the date of first production, saltwater disposal, 

or enhanced recovery operations. For workovers or re-entries, enter 

the date of resumed production, saltwater disposal, or enhanced 

 recovery operations.

9d. Producing Method. Mark the appropriate box to indicate by which 

method the subject well is producing: flowing, pumping, gas lift, 

or other. If the “other” box is marked, write in a brief explanation of 

the producing method.

9e. Estimated Production Per 24 Hours. Enter the following 

information regarding the estimated production from the subject well 

over a 24-hour period:

 9e(1). Oil Bbls. Enter the estimated number of barrels oil produced 

from the subject well in a 24-hour period.

 9e(2). Gas Mcf. Enter the estimated amount of gas produced from 

the subject well in a 24-hour period, expressed in thousands 

of cubic feet.

 9e(3). Water Bbls. Enter the estimated number of barrels water 

produced from the subject well in a 24-hour period.

 9e(4). Gas-Oil Ratio. Enter the gas-oil ratio for production from the 

subject well.

 9e(5). Gravity. The API gravity (density) of produced oil, measured 

in degrees.

 9e(6). Disposition of Gas. Mark the appropriate box to indicate 

the disposition of any gas produced from the subject well as 

vented, sold, or used on lease. If the gas is vented, you must 

submit an ACO-18 with the ACO-1.

 9e(7). Method of Completion; Production Interval. Mark the 

appropriate box to indicate if the production interval in the 

subject well is open hole, perforated, dually completed, 

commingled, or other. If the “other” box is marked, specify 

the method of completion in the blank provided. If the subject 

well is producing from commingled zones, you must file an 

ACO-4 form. If the subject well is dually completed, you must 

file an ACO-5 form.

 9e(8). Production Interval. Enter the footages where the wellbore 

is perforated.

Section 10: Hydraulic Fracturing Fluid Product Component Information 

Disclosure

Section 10 must be completed if Question 3 in Section 7(f) was marked 

“No”. In other words, Section 10 must be completed for each hydraulic 

fracturing treatment using more than 350,000 gallons of base fluid, if 

the operator has not submitted all of the required information to FracFocus. 

“Hydraulic fracturing treatment” means all stages in a well completion 

utilizing hydraulic fracturing fluid.

10a. Last Fracture Date. Enter the date on which the operator concluded 

fracturing at the well.

10b. County. Enter the county where the well is located.

10c. API Number. Enter the API number of the well.

10d. Operator Name. Enter the operator’s full name as it appears on 

the operator’s license.

10e. Well Name and Number. Enter the well name and well number.

10f. Latitude. Enter the GPS latitude for the well.

10g. Longitude. Enter the GPS longitude for the well.

10h. Datum. Provide the horizontal reference datum used with the GPS 

reading (NAD 27, NAD 83, WGS 84).

10i. Production Type. Describe the type of completion, as listed in 

section 1k on the first page of the ACO-1.

10j. True Vertical Depth (TVD). Enter the true vertical depth of the well.
Kansas Corporation Commission | oil & Gas Conservation Division

Form ACO-1 Instructions | Page 3 

July 2014

10k. Total Base Fluid Volume (gal). Enter the volume in gallons the total 

base fluid used.

10l. Hydraulic Fracturing Fluid Composition. 

10l(1) through 10l(8) must be provided for each base fluid, proppant, 

and chemical constituent used in each hydraulic fracturing 

treatment, unless it is the incidental result of a chemical process or 

a naturally occurring material that becomes part of the fluid during 

the hydraulic fracturing treatment. Fluids/proppants/chemical 

constituents subject to 29 CRF 1910.1200(i) appear on material 

safety data sheets (MSDS), and must be listed at the top of the page. 

All other fluids/proppants/chemical constituents must be listed at the 

 bottom.

10l(1). Trade Name. Enter the trade name for each fluid/

proppant/chemical constituent.

10l(2). Supplier. Enter the supplier name for each fluid/proppant/

chemical constituent.

10l(3). Purpose. Enter the purpose of each fluid/proppant/

chemical constituent.

10l(4). Ingredients. Enter the ingredients of each fluid/proppant/

chemical constituent. If the ingredients are a trade secret, 

enter “Trade Secret” in this section.

10l(5). Chemical Abstract Service Number (CAS #). Enter the 

CAS # for the fluid/proppant/chemical constituent.

10l(6). Maximum Ingredient Concentration in Additive (% 

by mass). Enter the maximum concentration, as part 

of the additive, by percent mass, of each proppant/

chemical constituent. That is, exclude the base fluid from 

the percent mass calculation. Enter “N/A” for the base 

fluid. Enter a percentage in this column for each other 

proppant/constituent.

10l(7). Maximum Ingredient Concentration in HF Fluid (% 

by mass). Enter the maximum concentration, as part 

of the hydraulic fracturing fluid, of each fluid/proppant/

chemical constituent. In other words, include the base fluid 

in the percent mass calculation. Enter a percentage for 

the base fluid, and also for each proppant and other 

constituent.

10l(8). Authorized Representative’s Name, Address, and 

Phone Number. For any fluid/proppant/chemical 

constituent labeled a “Trade Secret” in 10L(4), list the 

name, authorized representative, mailing address, and 

phone number of the party claiming the trade secret. If the 

fluid/proppant/chemical constituent is not a trade secret, 

this section may be left blank.

10m. Non-MSDS Data. For non-MSDS fluids/proppants/constituents, 

enter the data for 10l(1) through 10l(8) here.

Section 11: Information to attach to the ACO-1 for Mississippi horizontal 

wellbores

1. Attach a directional survey indicating the final path of the horizontal 

wellbore.

2. Attach a plat map depicting the well as it is drilled.

a. For horizontal wellbores completed open hole, the plat must 

depict the surface location, the point at which the wellbore 

encounters the producing formation (depth and distance from 

the nearest lease or unit boundary line), any isolation packers 

and the terminus of the wellbore (depth and distance from 

the nearest lease or unit boundary line). The lease and unit 

boundaries must be clearly depicted. Include GPS latitude and 

longitude readings for each point and specify which GPS planar 

projection was used to determine any footages listed on the 

map.

b. For cased horizontal wellbores, upload a plat that shows the 

well as it is drilled, including the surface location, the point the 

wellbore enters the producing formation (depth and distance 

from the nearest lease or unit boundary line), the location of 

the first perforation (depth and distance from the nearest lease 

or unit boundary line), the location of the last perforation (depth 

and distance from the nearest lease or unit boundary line), 

and the terminus of the wellbore (depth and distance from 

the nearest lease or unit boundary line). The lease and unit 

boundaries must be clearly depicted. Include GPS latitude and 

longitude readings for each point and specify which GPS 

planar projection was used to determine any footages listed on 

the map.

3. All operators must certify that the information contained on the plat 

depicting the well as drilled is accurate. Also, all operators must 

retain the well’s completion information depicting how the wellbore 

was perforated for the life of the well and make it available upon 

 Commission request.
KANSAS CORPORATION COMMISSION

OIL & GAS CONSERVATION DIVISION

WELL COMPLETION FORM

WELL HISTORY - DESCRIPTION OF WELL & LEASE

Form ACO-1

Jully 2014

Form must be Typed

Form must be Signed

All blanks must be Filled

OPERATOR: License #

Name:

Address 1: 

Address 2:

City: State: Zip: +

Contact Person:

Phone: ( )

CONTRACTOR: License #

Name:

Wellsite Geologist:

Purchaser:

Designate Type of Completion:

 New Well Re-Entry Workover

Oil WSW SWD SIOW

Gas D&A ENHR SIGW

OG GSW Temp. Abd. 

CM (Coal Bed Methane) 

Cathodic Other (Core, Expl., etc.): 

If Workover/Re-entry: Old Well Info as follows:

Operator:

Well Name:

Original Comp. Date: Original Total Depth:

 Deepening Re-perf. Conv. to ENHR Conv. to SWD

 Plug Back Conv. to GSW Conv. to Producer

 Commingled Permit #:

 Dual Completion Permit #:

 SWD Permit #:

 ENHR Permit #:

 GSW Permit #:

Spud Date or Date Reached TD Completion Date or

INSTRUCTIONS: The original form shall be filed with the Kansas Corporation Commission, 130 S. Market - Room 2078, Wichita, Kansas 67202, within 120 

days of the spud date, recompletion, workover or conversion of a well. If confidentiality is requested and approved, side two of this form will be held confidential for a period of 2 years. Rules 82-3-130, 82-3-106 and 82-3-107 apply. Drill Stem Test, Cement Tickets and Geological Well Report must be attached.

API No. 15 -

Spot Description:

- - - Sec. Twp. S. R. East West

 Feet from North / South Line of Section

 Feet from East / West Line of Section

Footages Calculated from Nearest Outside Section Corner:

 NE NW SE SW

GPS Location: Lat: , Long: 

Datum: NAD27 NAD83 WGS84

County:

Lease Name: Well #:

Field Name:

Producing Formation:

Elevation: Ground: Kelly Bushing:

Total Vertical Depth: Plug Back Total Depth:

Amount of Surface Pipe Set and Cemented at: Feet

Multiple Stage Cementing Collar Used? Yes No

If yes, show depth set: Feet

If Alternate II completion, cement circulated from:

feet depth to: w/ sx cmt.

Drilling Fluid Management Plan

(Data must be collected from the Reserve Pit)

Chloride content: ppm Fluid volume: bbls

Dewatering method used:

Location of fluid disposal if hauled offsite:

Operator Name:

Lease Name: License #:

Quarter Sec. Twp. S. R. East West

County: Permit #:

KCC Office Use ONLY

 Confidentiality Requested

 Date:

Confidential Release Date:

Wireline Log Received

Geologist Report Received

 UIC Distribution

 ALT I II III Approved by: Date:

AFFIDAVIT

I am the affiant and I hereby certify that all requirements of the statutes, rules and 

regulations promulgated to regulate the oil and gas industry have been fully complied 

with and the statements herein are complete and correct to the best of my knowledge.

Signature:

Title: Date:

Recompletion Date Recompletion Date

Confidentiality Requested:

 Yes No

(e.g. xx.xxxxx) (e.g. -xxx.xxxxx)

1a

1b

1c

1c

1d 1d 1d 1d

1e

1f 1f

1g

1h

1i

1j

1k

1l (1)

1l (2)

1l (3) 1l (4)

1l (5)

1m 1n 1o

1p

1q

1q 1q 1q 1q

1r (1)

1r (2)

1s

1s (1) 1s (2)

1s (3)

1t

1u 1u

1v

1w

1x (1) 1x (2)

1y 1z

1aa

1bb (1)

1bb (2)

1cc

1cc 1cc

2a 2b

2c

2d (1)

2d (2) 2d (3)

2d (4) 2d (4) 2d (4) 2d (4)

2d (5) 2d (6)

3a

3b 3c

0a
Operator Name: Lease Name: Well #:

Sec. Twp. S. R. East West County:

INSTRUCTIONS: Show important tops of formations penetrated. Detail all cores. Report all final copies of drill stems tests giving interval tested, time tool 

open and closed, flowing and shut-in pressures, whether shut-in pressure reached static level, hydrostatic pressures, bottom hole temperature, fluid recovery, 

and flow rates if gas to surface test, along with final chart(s). Attach extra sheet if more space is needed. 

Final Radioactivity Log, Final Logs run to obtain Geophysical Data and Final Electric Logs must be emailed to kcc-well-logs@kcc.ks.gov. Digital electronic log 

files must be submitted in LAS version 2.0 or newer AND an image file (TIFF or PDF).

Page Two

Drill Stem Tests Taken Yes No

(Attach Additional Sheets)

Samples Sent to Geological Survey Yes No

Cores Taken Yes No

Electric Log Run Yes No

List All E. Logs Run:

 Log Formation (Top), Depth and Datum Sample

Name Top Datum

CASING RECORD New Used

Report all strings set-conductor, surface, intermediate, production, etc.

Purpose of String Size Hole

Drilled

Size Casing

Set (In O.D.)

Weight

Lbs. / Ft.

Setting

Depth

Type of 

Cement

# Sacks

Used

Type and Percent

Additives

ADDITIONAL CEMENTING / SQUEEZE RECORD

Purpose:

Perforate

Protect Casing

Plug Back TD

Plug Off Zone

Depth

Top Bottom Type of Cement # Sacks Used Type and Percent Additives

Shots Per Foot PERFORATION RECORD - Bridge Plugs Set/Type

Specify Footage of Each Interval Perforated

Acid, Fracture, Shot, Cement Squeeze Record

(Amount and Kind of Material Used) Depth

TUBING RECORD: Size: Set At: Packer At: Liner Run:

Yes No

Date of First, Resumed Production, SWD or ENHR. Producing Method:

Flowing Pumping Gas Lift Other (Explain)

Estimated Production

Per 24 Hours

Oil Bbls. Gas Mcf Gas-Oil Ratio Gravity

DISPOSITION OF GAS: METHOD OF COMPLETION: PRODUCTION INTERVAL:

Vented Sold Used on Lease

(If vented, Submit ACO-18.)

Open Hole Perf. Dually Comp.

(Submit ACO-5)

Commingled

(Submit ACO-4)

Other (Specify)

Water Bbls. 

Mail to: KCC - Conservation Division, 266 N Main St, Ste 220, Wichita, KS 67202-1513

1. Did you perform a hydraulic fracturing treatment on this well? Yes No (If No, skip questions 2 and 3)

2. Does the volume of the total base fluid of the hydraulic fracturing treatment exceed 350,000 gallons? Yes No (If No, skip question 3)

3. Was the hydraulic fracturing treatment information submitted to the chemical disclosure registry? Yes No (If No, fill out Page Three of the ACO-1)

4a 4b

4c 4c 4c 4d

5a

5b

5c

5d

5e

5f

6a

6b (1) 6b (2) 6b (3) 6b (4) 6b (5) 6b (6) 6b (7) 6b (8)

7a

7b 7c 7d 7e

7f

8a 8b 8c 8d

9a (1) 9a (2) 9a (3) 9b

9c

9d

9e (1) 9e (2) 9e (3) 9e (4) 9e (5)

9e (6) 9e (7)

9e (8)
* Total Water Volume sources may include fresh water, produced water, and/or recycled water. ** Information is based on the maximum potential for concentration and thus the total may be over 100%.

Ingredient information for chemicals subject to 29 CFR 1910.1200(i) and Appendix D are obtained from suppliers Material Safety Data Sheets (MSDS).

HYDRAULIC FRACTURING FLUID PRODUCT COMPONENT INFORMATION DISCLOSURE

Last Fracture Date: County: API Number:

Operator Name: Well Name and Number:

Latitude: Longitude: Datum:

Production Type: True Vertical Depth (TVD): Total Base Fluid Volume (gal)*:

Page Three

 Trade Name Supplier Purpose Ingredients Chemical Abstract

Service Number (CAS #)

Maximum Ingredient Concentration

in Additive (% by mass)**

Maximum Ingredient Concentration

in HF Fluid (% by mass)**

Authorized Representative’s 

Name, Address, and Phone Number

Hydraulic Fracturing Fluid Composition:

Ingredients shown above are subject to 29 CRF 1910.1200(i) and appear on Material Safety Data Sheets (MSDS). Ingredients shown below are Non-MSDS.

10a 10b 10c

10d 10e

10f 10g 10h

10i 10j 10k

10l (1) 10l (2) 10l (3) 10l (4) 10l (5) 10l (6) 10l (7) 10l (8)

10m