Nebraska Oil and Gas Conservation Commission

Form 5

 TYPE OF WORK Oil Well Gas Well Injection Well Directional Well 

WELL COMPLETION OR RE-COMPLETION REPORT 

Instructions: Within thirty days following the completion or re-completion of any well, the owner or operator shall submit the original of this form. The Commission will reproduce copies as required.

Geological information will be held confidential for a period of twelve months upon written request. If multiple completion, submit separate report for each completion. 

 Workover Deepen Plug Back Same Reservoir 

Operator

API Number Lease Name Well Number

Surface Location 

Qtr-Qtr. Sec. Twp. Rng. 

Spud Date Date Reached TD Date Completed Elevation

Measured Depth, Ft True Vertical Depth, Ft PBTD, Ft Single or Multiple Zone Completion

Purpose of 

String

Hole Size 

Inches 

Casing Size

Inches 

Weight 

LBS/Ft 

Casing

Grade

Setting Depths

 Top Bottom

Cement Volume and Type 

Sacks and Class 

Formation Top 

Perforation 

Bottom 

Perforation 

Shots/Ft Size and Type

 Tubing Size 

Inches 

Tubing Weight 

LBS/Ft 

Tubing 

Grade 

Tubing Setting Depth

Ft 

Packer Type or Model Packer Setting 

Depth, Ft 

Date of First Production Producing Method – Flowing, Pumping, Gas Lift Choke Size, Inches Flowing Tubing Pressure, PSIG 

RATE OF PRODUCTION 

24 HOUR TEST PERIOD 

Oil, BBLS Gas, MCF Water, BBLS

Disposition of Gas (Vented,

Flared, used on lease, sold)

I/We hereby swear that the statements herein made are complete and correct.

 

 Signature

 _____

 Printed or Typed Name & TItle

(If new well, complete Well 

Log on reverse side of form.) _________________________________________________________________

Rev. 12/02 Date

Oil and/or

Gas Purchaser

Gas/Oil Ratio,

SCF/BBL

Casing Pressure, PSIG

INITIAL PRODUCTION 

 Annulus Integrity Test, Annular

 Fluid and Surface Pressure, PSIG

TUBING and PACKER RECORD

Stimulation and/or Squeeze History

Summary of Fluid Types and Volumes 

PERFORATION and STIMULATION RECORD 

Estimated Top of Cement 

CASING, LINER and CEMENTING RECORD 

Type of Logs Run in Well 

Producing Interval(s) for this Completion - Top, Bottom, Name

Reference of Elevation

 KB____ DF____ GL___ 

Latitude and Longitude of Surface Location – Degrees and Minutes 

Bottom Hole Location if Well is Directionally Drilled – Footage (Report location from exterior section lines)

 Feet from N___ S ___ line Feet from E ___ W___ line of the Section 

Surface Location of Well – Footage (Report location from exterior section lines)

 Feet from N ___ S ___ line Feet from E ___ W ___ line of the Section 

County

Field and Reservoir (If wildcat, so state)

Address 
WELL LOG 

Show important formations penetrated, with tops. Detail all cores. Report all drill stem tests, giving interval

tested, time tool open and closed, flowing and shut-in pressures, whether shut-in pressure reached static level, 

fluid recovery and flow rate if gas to surface during test. Enclose one copy of each open-hole log run in well. 

FORMATION RECORD 

Formation Name Top of Formation

Measured Depth, Ft

Top of Formation

True Vertical Depth, Ft if Directional Well

CORING RECORD 

Formation Name Interval Cored Core Recovery, Feet

DRILL STEM TESTS 

DST 

Number

Top of 

Interval 

Bottom of 

Interval 

IHP IFBHP

 Pressure Time

Enclose one copy of the core analysis with this Form 5. 

ISIBHP

Pressure Time

FFBHP

Pressure Time

FSIBHP

Pressure Time

FHP Description of Pipe Recovery

Additional Information

Additional Information 

Additional Information 

Additional Information 

Additional Information: