## 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 1Classyield per sack Stage 2 or total volume if 1 stage Stage 2 ortotal 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 ce ment data is not reported. In Part III, enter the volume o f 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 s ubmit 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 Saltwate r Disposal wells, the well c onstruction 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 subm it 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 to tal depth to surface as required by the division rules. Rep orting only certain formation tops is not adequate. 8. Additional construction or comple tion details and any comments or notes should be submitted on a separate sheet.