WELL COMPLETION/ 

RE-COMPLETION REPORT

State Form 55079 (8-12) / Form No. R3 

INDIANA DEPARTMENT OF NATURAL RESOURCES 

Division of Oil and Gas 

402 W. Washington St., Rm. 293 

Indianapolis, IN 46204 

Phone (317) 232-4055 

FAX (317) 232-1550 

Internet: http://www.in.gov/dnr/dnroil/ 

Purpose of report

 - Completion Re-completion Conversion 

 Check here if you want the completion 

information to remain confidential for 1 year.

FOR STATE USE ONLY 

Date filed Date released 

PART I GENERAL INFORMATION

Name of operator 

 

Telephone number 

 ( ) - 

Permit number 

 

Address of operator ( Check here if this is a new address ) 

 

City 

 

State 

 

ZIP code 

 

PART II LOCATION INFORMATION

Name of lease 

 

Well number 

 

Elevation (G.L.) 

 

Section 

 

Township 

 

Range 

 

1⁄4 

 

1⁄4 

 

1⁄4 

 

Footage’s: ft. from N, S, NW, SE line

 ft. from E, W, NE, SW line

County 

 

Distance to the nearest well capable of producing from the same formation ft. 

 Note: This information is only required for Oil, Gas, CBM and Dual completion wells. 

PART III WELL CONSTRUCTION 

Casing Specifications Cement (In Sacks or Cubic Feet) Hole 

Casing size O.D. 

( Inches) 

Wt./ ft. 

( lbs. ) - 

Grade 

Setting 

depth 

Stage 1 

Volume 

Stage 1 

Classyield per sack 

Stage 2 or 

total 

volume if 

1 stage 

Stage 2 or 

total Classyield per sack 

Depth Diameter 

(Inches) 

Surface 

 

 lbs. 

- 

 ft. 

- 

 

- 

 ft. 

Intermed. 

 

 lbs. 

- 

 ft. 

- 

 

- 

 ft. 

Long str. 

 

 lbs. 

- 

 ft. 

- 

 

- 

 ft. 

Liner 

 

 lbs. 

- 

 ft. 

- 

 

- 

 ft. 

Tubing lbs. 

- 

 ft. 

Packer setting depth ft. 

Packer setting depth ft. 

Packer setting depth ft. 

CIBP depth ft. 

CIBP depth ft. 

 

Centralizers at ft. ft. ft. ft. ft. ft. ft. ft. 

Casing perforated From ft. to ft. formation 

 From ft. to ft. formation 

 From ft. to ft. formation 

 From ft. to ft. formation 

Open hole: From ft. to ft. formation 

PART IV COMPLETION INFORMATION 

Declination type ( Check one only ) If Horizontal, enter: 

 Vertical Directional Horizontal Azimuth: deg. Lateral length: ft. 

Completion type ( Check one only ) 

 Dry hole Gas storage/ observation well Dual completion Oil/ Class II well 

 Oil well Geologic/ structure test well Dual completion Gas/ Class II well 

 Gas well Enhanced recovery Class II well Non potable water supply well 

 Non commercial gas well Saltwater disposal Class II well Coal Bed Methane well 

Date (Enter one only) Tools Total Depths: 

 Drillers/TVD ft. Loggers ft. 

 TMD      ft. PBTD ft. 

 Completed . 

 Re-completed Rotary from ft. to ft. 

 Converted Cable from ft. to ft. Type of plugback: 

Drilling Contractor or Company: 

IMPORTANT: THIS FORM MUST BE SUBMITTED WITHIN 30 DAYS AFTER THE WELL COMPLETION OR RE-COMPLETION 

Continued on next page 
PART IV Cont’d. COMPLETION INFORMATION 

Completion formation Completion Intervals Well Treatments 

 Name 

 Production Injection 

From ft. to ft Acidized with       gallons 

Name 

 Production Injection 

From ft. to ft Acidized with gallons 

Name 

 Production Injection 

From ft. to ft Shot with quarts 

Geophysical Logs Initial production (First 24 hours) 

 

 

 Oil barrels Water barrels Gas MCF 

 

 

 

 

PART V OIL AND GAS OCCURRENCES 

Intervals Formation Names/Types Special Test Descriptions 

(DST’s, Pump tests, Fill ups, etc...) 

From      ft. to ft 

From      ft. to      ft 

From      ft. to ft 

PART VI FORMATION INFORMATION 

Intervals Rock Description 

From      ft. to      ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

From      ft. to ft 

Intervals Rock Description 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

From ft. to ft 

PART VII AFFIRMATION 

I affirm under penalty of perjury that the information provided in this report is true to the best of my knowledge and belief. 

Signature of operator or authorized agent Date signed 

 

Special Requirements

1. Only those persons whose names appear in PARTS V or VI of the Organizational Report are authorized to sign this report. 

2. This report will be returned as unacceptable if all casing and cement data is not reported. In Part III, enter the volume of cement used in sacks or 

cubic feet, the cement yield in cubic feet/sack and the cement class or type. 

3. If this is a directional or horizontal well you must submit a copy of the directional survey with this report. 

4. You must submit 2 copies of ALL geophysical logs run on this well. 

5. For Class II Enhanced Recovery and Saltwater Disposal wells, the well construction information must match the specifications of the written permit. 

If the information is different you must submit form no. A7 to request a modification of the existing permit conditions. 

6. If this well has been hydraulically fractured, you must submit form no. R15 along with this completion report. If the well has been acidized but not 

fractured, report that information in Part IV above. 

7. In Part VI, describe ALL lithology that has been drilled from total depth to surface as required by the division rules. Reporting only certain formation 

tops is not adequate. 

8. Additional construction or completion details and any comments or notes should be submitted on a separate sheet.