# ILLINOIS DEPARTMENT OF NATURAL RESOURCES Office of Oil an d Gas One Natural Resources Way (217) 782
- 7 756 Springfield, Illinois 62702-1271 

# OG-9 WELL COMPLETION REPORT TYPE OF REPORT : 

# 9 NEW WELL 

# 9 CONVERSION 

# 9 DOPH 

# 9 DEEPENING 

# 9 WORKOVER TYPE OF WELL : 

# 9 OIL PRODUCER 

# 9 GAS PRODUCER 

# 9 CLASS II INJECTION WELL 

# 9 WATER SUPPLY 

# 9 OBSERVATION 

# 9 GAS STORAGE 

# 9 D&A 

# 9 SERVICE 

# 9 COAL BED GAS 

# 9 COAL MINE GAS PERMITTEE: __________________________________________________ PERMITTEE #:___________________ WELL NAME: _________________________________________________ PERMIT #: _______________________ LOCATION: __________________________________________________ REFERENCE #: __________________ COUNTY: ________________________ SECTION: __________ TOWNSHIP: _________ RANGE: ___________
DRILLING DATA : 

# 9 WELL NOT DRILLED, PERMIT EXPIRED 

# 9 WELL NOT CONVERTED, PERMIT EXPIRED DATE DRILLING BEGAN: __________________________________ FINISHED: _______________________ ELEVATION: KB ____________ DF ____________ GR ____________ ROTARY: FROM __________ TO __________ CABLE: FROM __________ TO __________ T.D.: __________________________ P.B.T.D. ____________________________


### TEST DATA: WERE ELECTRIC OR OTHER WIRELINE LOGS RUN: YES NO TYPE OF LOG: ___________________________________________________________DATE: _____________________ TYPE OF LOG: ___________________________________________________________DATE: _____________________ TYPE OF LOG: ___________________________________________________________DATE: _____________________ WAS WELL CORED: YES NO INTERVAL CORED: ____________________________ DRILL STEM TEST RUN: YES NO ZONE TESTED: ___________________________


### CONSTRUCTION DATA :

CASING SIZE SETTING DEPTH SACKS

CEMENT HOLE

SIZE TOP OF

CEMENT TOP

DETERMINED BY SURFACE
INTERMED./MINE STRING / OR LINER PRODUCTION
OTHERTU BI N G : TY PE: ___ _______________________________________________ SI ZE: ___ _______________

PAC K ER : 1 . BR A N D A N D TY PE: ___ ______________________ SETT I N G D EPTH : ___ _______________

2. BR A N D A N D TY PE: ___ ______________________ SETT I N G D EPTH : ___ _______________ W ELL CO M P LETI ON DA TA FOR PROD UC TI ON /I NJECTI ON F OR M ATI ON S: F ORMAT I ON N A ME L I T H O L O G Y PE R F. I NTERV AL OP EN

HOLE I NTERV AL ACI DI Z ED /F RACTURED /OTHER

( LI S T AMO UNTS US ED AND OTHE R

DETA I LS)

P RODUCTI ON I NF ORM ATI ON: PRO D U CI N G FO RM A TI O N S: ___ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ___ D A TE O F FI RST PRO D U CT I O N ( O I L TO TA N K ) ___ ____ ____ ____ ____ ____ ____ ____ ____ D A TE O F TEST : ( STA RT ED TEST IN G TO TA N K ) ___ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ _ LEN G TH O F TEST : ___ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ___ INI TI AL PROD UCTI ON RATE: OI L _

_ _ _ _ _ _ _ _ _ BB LS P ER DAY WATER _ _ _ _ _ _ _ _ _ _ BB LS P ER DAY GAS _ _ _ _ _ _ _ _ _ _ M CF
I NJ ECTI ON I NF ORM ATI ON: IN J EC TI O N /D I SPO SA L FO RM A TI O N ( s ) : ___ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ___ T Y P E O F IN J E C T E D F L U I D : 

# 9 F RE S HW ATE R 

# 9 S ALT W ATE R 

# 9 O TH ER ( SPEC I FY ) ___ ____ ____ ____ __ SO U RC E O F IN J EC TED FLU I D : ___ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ _ D A TE O F FI RST IN J EC TI O N : ___ ____ ____ ____ ____ ____ ____ ____ R A T E P E R D A Y : _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ B B L S W A T E R A T _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ P S I.

_______________________ M C F G A S A T _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ P S I. UNDER P ENALT I ES OF P ERJ URY, I DECL ARE T H A T I H A VE EX AM I NED T HI S REP ORT, I NCLUDI NG ACC OM P ANYI NG S TATE M ENTS AND DOCUM ENTS , AND TO T HE BE S T OF M Y KNOW LEDGE, I T I S TRUE , CORRECT, AND COM P LET E.

____ ________ ________________________________________ ____________________________________________ ___ S I GNATURE OF P ERM I TTE E OR DES I GNEE TI TLE

____ ________ ________________________________________ ____________________________________________ ___ ADDRES S DATE

____ ________ ________________________________________ CI TY, S TATE

T hi s stat e agency i s requ esting d escl osu re o f i nf orm at i on t hat i s necessary t oaccom pl i sh t he st at uory pu rpose as outl i ned i n the I l l
. C om pl i l ed S t at . C h. 2 25 p ars. 72 5 et . s eq. F ai l ure t o di scl ose t hi s i nf orm at i on w i l l resul t i n thi s f

orm no t bei ng p rocessed
. Thi s f orm has been app roved by t eh F orm s M anagem ent C ent er. I L 472- 0242 ( Re v 2/ 12)