Original Recompletion of New Zone Workover of Dry Type Well: Oil DrySWD/ Gas Other Commingle, Well Conversion Existing Zone Hole Gas EOR Condensate
Field Address Pool Completed in City No. State Zip Sec. Rge. Phone Fax Work Completed E-Mail KB GL DF Total Depth Drilled Electric Log Run: Filed: Conductor: (Size & Wt.) set at ft. w/ sks. set at ft. w/ sks. set at ft. w/ sks. set at ft. w/ sks. set at ft. ft. Perforated/Open Hole Intervals Is this a commingle of existing zones? Plugged Back TD Electric Log Run: Filed: Plugged Back BHL Liner: (Size & Wt.) From ft. to ft. w/ sks. Tubing: (Size & Wt.) set at ft. Packer Depth ft. Perforated/Open Hole Intervals w/ 

### gals. w/ w/ Describe Work: Is this well the only completion in the common source of supply within the unit? If no, have additional completion(s) been authorized by General Rule or appoved by Commission Order? Disposition of gas from this well: Test Length hrs. Production Method: Tubing Pressure Casing Pressure BHP Net Oil in 24 Hours: bbls. SW 

### bbls. Gravity Oil MCF 

### bbls. A PI No. 03 - Well Name Permit No.

Elevation: (Date) SECTION B - FILL OUT FOR NEW WELLS Bottom hole location Twp.

SECTION D - WELL TREATMENT (See instructions on back) Commingle approved by General Rule or Commission Order? Tubing: (Size & Wt.) Packer Depth

Choke/Orifice Size: Date of Test: SECTION F - PRODUCER'S PRODUCTION TEST (See instructions on back) Est. Daily Gas Well SW: Estimated Daily Gas Production Rate (24 Hrs.): CERTIFICATE I declare under the penalties of perjury that this report has been examined by me and to the best of my knowledge is true, correct, and complete. Signature Typed or Clearly Printed Name Revised 04/09 

# FORM 3 PRODUCER'S WELL COMPLETION AND RECOMPLETION REPORT Brine SECTION A - WELL DESCRIPTION - MUST BE COMPLETED Completion Producer's Name County (Date) Work Commenced
PBTD Drilling Unit Description: Surface: (Size & Wt.) Production: (Size & Wt.) Intermediate: (Size & Wt.) SECTION C - FILL OUT FOR RECOMPLETION OF NEW ZONE, WORKOVER, COMMINGLE OR CONVERSION

Fractured: Interval Acidized: Interval
SECTION E - PRODUCTION INFORMATION (See instructions on back) lbs. of sand bbls. of fluid type of fluid

GOR WHSIP Surface hole location 

# ARKANSAS OIL AND GAS COMMISSION

Yes No Yes No

Yes No

Yes No Yes No

Vented (approval required) Lease Fuel Sold Flowing Gas Lift Rod Pump Cent. Pump

Y es No No Y es Yes No Yes No 

### Submit Form To Appropriate District Office: Fort Smith Regional Office 3309 Phoenix Avenue Fort Smith, Arkansas 72903 El Dorado Regional Office P. O. Box 11510 El Dorado, Arkansas 71731

Yes No

# INSTRUCTIONS FOR FILING FORM 3 1.

4. For workovers of previously completed zones in existing wells, complete Sections A, C, D and F. 5. For conversion of a producing well into use as a SWD/EOR well, check the "Recompletion of New Zone, Commingle or Well Conversion" box and "SWD/EOR" box at to pof Form and com p lete Sections A , C and D. For commingle of zones in an existing well, check the "Recompletion of New Zone or Commingle" box and "Type of Well" box at to pof Form and com p lete Section A and answer the commin g le q uestions in Section C. For completion of a new zone in an existing well, check the "Recompletion of New Zone or Commingle" box and "Type of Well" box at to pof Form and com p lete Sections A, C, D, E, and F. 3. Form 3 is required to be submitted in accordance with General Rule B-5, or wiithin 30 days of the plugging of a dry hole. Please check the appropriate office where form is to be sent.

7. 6. For a dry hole, check "Dry Hole" box and "Type of Well" box at top of Form and complete Sections A and B. For newly drilled wells check the "Original Completion" box and "Type of Well" boxes at top of Form and complete Sections A, B, D, E and F. 2.