# K ANSAS 

# C ORPORATION 

# C OMMISSION 

## O IL & 

## G AS 

## C ONSERVATION 

## D IVISION 

# 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 Worko ver

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 E NHR 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 confi

dential 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: Set At: Size: Packer At: Liner Run: Yes No

Date of First, Resumed Production, SWD or E NHR. 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 Ver tical Depth (TVD): Total Base Fluid Volume (gal)*: **Page Three**

Trade Name Supplier Purpose Ingredients Chemical Abstract Service Number (CAS #) Maximum Ingredient Con c entration in Additive (% by mass)** Maximum Ingredient Con c entration 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.**

# K ANSAS 

# C ORPORATION 

# C OMMISSION 

## O IL & 

## G AS 

## C ONSERVATION 

## D IVISION 

# WELL COMPLETION (FORM ACO-1) Instructions **Form ACO-1 Instructions** July 2014

**General Instructions.** 1. The form m ust be typed. 2. All horizontal w ellbore completions are required to attach the additional information with their A CO-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 Conser vation Staff need to contact the operator about the For m. 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-entr y, 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, pr ior 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 or iginally 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 Stora**  **ge.** Mark the appropriate box(es) to indicate whether, through w orkover/re-entry operations, the w ell has been deepened, re-perforated, and/or conver ted to an enhanced recovery or saltwater disposal well. Multiple bo xes may be marked. For each box that is marked, enter the corresponding per mit 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 w as 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, To wnship, and Range. Mark the appropriate box to indicate if the range is east or west of the Sixth Pr incipal Meridian. 1r. **Footage Location from Section Lines.** 1r(1). Enter the number of feet the subject w ell 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 w ell 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 availab le 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 dur ing 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). Mar k the box to show if a multiple stage cementing collar was used to complete/recomplete the well. 1bb(2). If a m ultiple 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 b y 1⁄4, Section, Township , and Range. Mark the box to indicate if the Range is East or West of the Sixth Pr incipal 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 recover y or disposal well, enter the permit number under which the operator is author ized 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.K ansas C orporation C ommission | o il & G as C onservation D ivision **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 W est 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” bo x, 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 stor age formation, the formation top, and the datum of the formation top. The formation datum is the distance from the for mation 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 follo wing 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 f oot. 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 Inter**  **val Perforated.** Enter the type of bridge plugs, the depth the bridge plugs are set f or each interval perforated, and the depth of each perfor ated interval. 8c. **Acid, Fracture, Shot, Cement Squeeze Record.** Enter the amount and kind of material used f or any acid, fracture, or shot treatment, and any cement squeez e at each perforation interval. 8d. **Depth.** Enter the depth of the acid, fracture, shot, or cement squeeze at each perfor ation 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 w ell. 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 recov ery 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 per iod. 9e(2). **Gas Mcf.** Enter the estimated amount of gas produced from the subject well in a 24-hour per iod, 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 per iod. 9e(4). **Gas-Oil Ratio.** Enter the gas-oil ratio for production from the subject w ell. 9e(5). **Gravity.** The API gravity (density) of produced oil, measured in deg rees. 9e(6). **Disposition of Gas.** Mark the appropriate box to indicate the disposition of any gas produced from the subject w ell as vented, sold, or used on lease . If the gas is vented, you must submit an ACO-18 with the A CO-1. 9e(7). **Method of Completion; Production Interval.** Mark the appropriate bo x 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 pro vided. If the subject well is producing from commingled z ones, you must file an ACO-4 f orm. 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 perf orated.
**Section 10: Hydraulic Fracturing Fluid Product Component Information Disclosure**  Section 10 must be completed if Question 3 in Section 7(f) w as 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 hydr aulic fracturing fluid. 10a. **Last Fracture Date.** Enter the date on which the operator concluded fractur ing 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.K ansas C orporation C ommission | o il & G as C onservation D ivision **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 hydr aulic fracturing treatment, unless it is the incidental result of a chemical process or a naturally occurr ing material that becomes part of the fluid during the hydr aulic fracturing treatment. Fluids/proppants/chemical constituents subject to 29 CRF 1910.1200(i) appear on material safety data sheets (MSDS), and m ust 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 ing redients are a trade secret, enter “T rade 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 f or each other proppant/constituent. 10l(7). **Maximum Ingredient Concentration in HF Fluid (% by**  **mass).** Enter the maximum concentration, as part of the hydr aulic fracturing fluid, of each fluid/proppant/ chemical constituent. In other w ords, include the base fluid in the percent mass calculation. Enter a percentage f or 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 “T rade Secret” in 10L(4), list the name, author ized representative, mailing address, and phone number of the par ty claiming the trade secret. If the fluid/proppant/chemical constituent is not a trade secret, this section may be left b lank. 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 surv ey indicating the final path of the horizontal wellbore. 2. Attach a plat map depicting the well as it is dr illed.
a. For hor izontal wellbores completed open hole, the plat must depict the surface location, the point at which the w ellbore encounters the producing for mation (depth and distance from the nearest lease or unit boundary line), an y isolation packers and the termin us of the wellbore (depth and distance from the nearest lease or unit boundary line). The lease and unit boundaries m ust be clearly depicted. Include GPS latitude and longitude readings for each point and specify which GPS planar projection was used to deter mine any footages listed on the map. b. For cased hor izontal wellbores, upload a plat that shows the well as it is dr illed, including the surface location, the point the wellbore enters the producing f ormation (depth and distance from the nearest lease or unit boundary line), the location of the first perfor ation (depth and distance from the nearest lease or unit boundary line), the location of the last perf oration (depth and distance from the nearest lease or unit boundary line), and the termin us of the wellbore (depth and distance from the nearest lease or unit boundary line). The lease and unit boundaries m ust be clearly depicted. Include GPS latitude and longitude readings for each point and specify which GPS planar projection was used to deter mine any footages listed on the map. 3. All operators m ust certify that the information contained on the plat depicting the well as dr illed is accurate. Also, all operators must retain the well’ s completion information depicting how the wellbore was perf orated for the life of the well and make it available upon Commission request.

# K ANSAS 

# C ORPORATION 

# C OMMISSION 

## O IL & 

## G AS 

## C ONSERVATION 

## D IVISION 

# 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 Wor kover

Oil WSW SWD SIOW
Gas D&A ENHR SIGW
OG GSW T emp. 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 E NHR Conv. to SWD Plug Back Conv. to GSW Conv . to Producer

Commingled Permit #: Dual Completion P ermit #:
SWD Per mit #:
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 confi

dential 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. T wp. S. R. East West

Feet from Nor th / 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? Y es 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 0aOperator 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: Set At: Size: Packer At: Liner Run: Yes No

Date of First, Resumed Production, SWD or E NHR. 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: W ell Name and Number:

Latitude: Longitude: Datum:

Production Type: Tr ue 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