Nebraska Oil and Gas Conservation Commission

Form 5



## TY PE OF WORK O il Well G a s Well Injection Well Directional Well 

# WELL COMPLETION OR RE -COMPLETION REPORT

Inst ruct ions: W i t h i n thi r ty day s f o l l o w i ng th e compl e ti on or r e

- c o m pl eti on o f a n y w e l l

, t he ow ner or

oper ator shal l submi t t h e or i g i nal of t h i s for m . The C o m m i ssi on w i l l r e pr oduce copi es as r e q u i r e d

. Geolo g i c al i n for m a t i on w i l l be hel d con f i den ti a l for a p er i o d o f tw el v e mon t hs u p o n w r itten r e q uest. I f m u lti p le c o m p letion , su bmit s e p ar at e r e p or t f o r

each co m p letion.



## Workover Deepen Plug Back Same Reservoir

Operat o r

AP I N u m b e r Lease N a me Well Numbe r

Surf ace Lo cat ion

Qt r- Qt r. Sec. Tw p

. Rng.

Spud Date D a t e R each ed TD Da te Comple te d Elev at ion

Measured D e pth, Ft True Verti cal D e pth, Ft PBTD, Ft Single or Multipl e Zo ne Completion

Purpose of

St rin g Hole Size

Inches C asing Siz e

Inches W e ight

LBS/Ft C asing

Grade Setting Depths

To p Bot t o m Cement Volume and T y pe

Sack s and C l as s

Formation Top

Perforation Bottom

Perforation Shots/Ft Size and T y pe

Tubing Size

Inches Tubing W e ight

LBS/Ft Tubing

Grade Tubing Setting Depth

Ft Pack er T y pe or Model Pack er S e t t i ng

De p th, Ft

Date of First Producti on Producing Method

– Flo w ing

, Pumping, G as Lift C hoke Siz e , Inch es Flo w ing Tubing Pre s sure, PSIG

R A TE OF P R ODUCTI O N

2 4 HOUR TE S T P E R I O D Oil, BBLS Gas, M C F W a te r, BBLS

Disposition of Ga s (V e n t e d

, Flared, u sed on l e a s e

, sold )

I/We hereby s w ear t h at t h e st at em ent s her e in mad e ar e compl e t e and cor r ect

.

S i g n a t u r e

__ __

_ P r i n t e d o r T y p e d N a m e & T I t l e

( I f n e w we l l

, c o m p l e te W e ll

L o g o n re ve rs e s i de of f o rm

. )

___ _ __

___ __

___ _ _ _ _ _ __

___ ___ __

___ __

__

___ ___ ___ _ _ ___ __

__

___ ___ _ __

__ Rev

. 12/02 Dat e Oil and/o r

Gas Purcha se r Gas/O il Rat i o,

S C F/BBL C asing Pr essur e, PS IG 

## INITIAL PR O D UCTIO N A nnulus Integrit y Test, A nnula r

Fluid and Surface P r essur e, P S IG 

## TUBING and PA CKER REC O RD Stimulation and/or S queeze Hi stor y

Summar y of Fluid T yp es and Volume s 

## PERF ORATI O N and STIMULATION REC O RD Estimated Top of Ce ment 

## CASIN G, LINE R and CEMENTIN G RE CORD T y pe of Logs Run in W e ll Producing Interv al(s) for this Completion - Top, Bottom, Name Reference of Elev ation

KB__

_ _ DF_

_ _ _ GL__

_ Latitude and Longitude of Surfac e Locatio n

– D e gre es and M i n u t es Bot t o m Hole Locat ion if Wel l i s Dire ct iona ll y Drilled

– Footage ( R eport location from exterior se ction line s )

Feet f r om N__

_ S

___ line Feet from E

___ W__

_ line of the Se ction Surf ace Lo cat ion of Well

– Footage (Report location from e x ter i or se ction line s )

Feet f r om N

__ _ S

__ _ line Feet f r om E

___ W

__ _ line of t h e Se ct ion Count y Field and Re serv oir (If w ildcat, so state) A d dress

## W E LL L O G

Sho w importa n t for m ati ons pe netrated, w i th tops. De tail all cores. Rep o rt all drill ste m te sts, gi v i ng i n te r v al

teste d , ti me to o l open a nd cl os ed, flo w ing and shut -in pre ssu res, w h ether sh ut-i n press ure r eached s t ati c le v e l,

fluid re co v e r y a nd fl o w rate if g as to s u rfac e du ring te st. En clo se one cop y of each o p en -h ole log ru n in w e ll.

FORM A T I O N R E CORD

Formation Name Top of Formation

M easured D e p th, Ft Top of Formation

True Verti cal D e p t h

, Ft if Direct ional W e ll



## CORI NG REC O RD

Formation Name Interv al Cored Core Re c o v e r y , Fe e t



## DRILL STEM TE STS

DS T

Numbe r Top of

Int e rv al Bottom of

Int e rv al IHP IFBHP

Pre ssure Time 

## Enclose one copy of the co re anal y s is w i th this For m 5.

ISIBHP

Pres sure Time FFBHP

Pres sure Time FS IBHP

Pres sure Tim e FHP D escript i on of Pip e R ecov e r y

A d ditional Information

A d ditional Information

A d ditional Information

A d ditional Information

A d ditional Information: