ILLINOIS DEPARTMENT OF NATURAL RESOURCES

Office of Oil and Gas

One Natural Resources Way

 (217) 782-7756 

 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

OTHER
TUBING: TYPE: __________________________________________________ SIZE: __________________

PACKER: 1. BRAND AND TYPE: _________________________ SETTING DEPTH: __________________

 2. BRAND AND TYPE: _________________________ SETTING DEPTH: __________________

WELL COMPLETION DATA FOR PRODUCTION / INJECTION FORMATIONS:

FORMATION

NAME

LITHOLOGY PERF.

INTERVAL

OPEN

HOLE

INTERVAL

ACIDIZED / FRACTURED / OTHER

(LIST AMOUNTS USED AND OTHER

DETAILS)

PRODUCTION INFORMATION:

PRODUCING FORMATIONS: __________________________________________________________________________

DATE OF FIRST PRODUCTION (OIL TO TANK) ___________________________________

DATE OF TEST: (STARTED TESTING TO TANK) ________________________________________________

LENGTH OF TEST: ______________________________________________

INITIAL PRODUCTION RATE:

OIL __________ BBLS PER DAY WATER __________ BBLS PER DAY GAS __________MCF

INJECTION INFORMATION:

INJECTION / DISPOSAL FORMATION(s): ______________________________________________________________

TYPE OF INJECTED FLUID: 9 FRESHWATER 9 SALTWATER 9 OTHER (SPECIFY) _________________

SOURCE OF INJECTED FLUID: ________________________________________________________________________

DATE OF FIRST INJECTION: _______________________________

RATE PER DAY: _______________________ BBLS WATER AT __________________PSI.

 _______________________ MCF GAS AT ___________________ PSI.

UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE EXAMINED THIS REPORT, INCLUDING

ACCOMPANYING STATEMENTS AND DOCUMENTS, AND TO THE BEST OF MY KNOWLEDGE, IT IS TRUE,

CORRECT, AND COMPLETE.

____________________________________________________ _______________________________________________

SIGNATURE OF PERMITTEE OR DESIGNEE TITLE

____________________________________________________ _______________________________________________

ADDRESS DATE

____________________________________________________

CITY, STATE

This state agency is requesting desclosure of information that is necessary toaccomplish the statuory purpose as outlined in the Ill. Compliled Stat. Ch. 225 pars. 725 et. seq. Failure to disclose this information

will result in this form not being processed. This form has been approved byt eh Forms Management Center.

IL 472-0242 (Rev 2/12)