8000-FM-OOGM0004b Rev. 12/2015

COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF ENVIRONMENTAL PROTECTION

OFFICE OF OIL AND GAS MANAGEMENT

Completion Report

DEP USE ONLY

Site ID Primary Facility ID

Client ID Sub Facility ID

NOTE: For information related to the submission of confidential proprietary information or trade secrets please see “Completion 

Report Instructions” and “Registration of Confidential Proprietary Information/Trade Secret Fluid Chemical Information,”

Doc. No. 8000-FM-OOGM0132” and instructions.

WELL INFORMATION

Well Operator: OGO No.: U.S. Well (API) No.:

37 - - - -

Well Farm Name: Well No.:

״ ׳ ° - LAT :Address

NAD 83

Project Number: Serial No.:

״ ׳ ° - LONG

City: State: Zip Code: Municipality: County:

Telephone No.: Fax No.: Email: USGS 7.5 min. quadrangle map: Section:

Check the appropriate submission type: Original Amendment Check if this is a re-stimulation operation: 

STIMULATION BASE FLUID

Water Sources Withdrawal Start Date Withdrawal End Date Volume (Gallons)

1.

2. 

3. 

4. 

5. 

Total Gallons from Water Sources:

Recycled Water Sources:

Total Gallons of Recycled Water: Total Gallons of Base Fluid (Water): DEP Biologist 

Review/Date

Other Base Fluid(s) Quantity / UOM

1. /

2. /

Total Quantity of Base Fluid(s) (Other): /

STIMULATION/PRODUCTION INFORMATION (WELL)

Radioactive tracers used:

Yes No 

If “Yes”, specify tracer(s): Commencement Date: Completion Date:

Open Flow (mcfd): Open Flow Measurement Method: Surface Pressure (psig): Surface Pressure Measurement Method: Intermediate Shoe Test Pressure (psig):

Well Products: Gas Btu: Oil API G: Condensate API G: Other: GOR: 

WELL SERVICE COMPANIES

Perforation Hydraulic Fracturing Plug Drill Out Flow Back

Name: Name: Name: Name:

Address: Address: Address: Address:

City – State – Zip Code: City – State – Zip Code: City – State – Zip Code: City – State – Zip Code:

Phone No.: Phone No.: Phone No.: Phone No.:

I do hereby certify to the best of my knowledge, information and belief that the information contained on this Completion Report is true and correct. I am 

aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment.

Well Operator’s Signature DEP USE ONLY

Reviewed by: Date: 

Printed Name / Title: Date: Comments: 

Sheet A

Page 1 of 
8000-FM-OOGM0004b Rev. 12/2015

Well API# 37- - - -

PERFORATION RECORD

Complete a separate record for each producing interval. For open-hole completions in which notching or other mechanical changes are made to the wellbore, 

separate record. Please insert additional copies of this sheet if additional rows are needed.

Perforation Date: Producing Interval 

Top TMD (ft.):

Producing Interval 

Bottom TMD (ft.):

Perforation Phasing 

(deg.):

No. of Perforations: Perforation Status: Perforation Status

Date:

Pro

Perforation Date: Producing Interval 

Top TMD (ft.):

Producing Interval 

Bottom TMD (ft.):

Perforation Phasing 

(deg.):

No. of Perforations: Perforation Status: Perforation Status

Date:

Pro

Perforation Date: Producing Interval 

Top TMD (ft.):

Producing Interval 

Bottom TMD (ft.):

Perforation Phasing 

(deg.):

No. of Perforations: Perforation Status: Perforation Status

Date:

Pro

Perforation Date: Producing Interval 

Top TMD (ft.):

Producing Interval 

Bottom TMD (ft.):

Perforation Phasing 

(deg.):

No. of Perforations: Perforation Status: Perforation Status

Date:

Pro

Perforation Date: Producing Interval 

Top TMD (ft.):

Producing Interval 

Bottom TMD (ft.):

Perforation Phasing 

(deg.):

No. of Perforations: Perforation Status: Perforation Status

Date:

Pro

Perforation Date: Producing Interval 

Top TMD (ft.):

Producing Interval 

Bottom TMD (ft.):

Perforation Phasing 

(deg.):

No. of Perforations: Perforation Status: Perforation Status

Date:

Pro

Perforation Date: Producing Interval 

Top TMD (ft.):

Producing Interval 

Bottom TMD (ft.):

Perforation Phasing 

(deg.):

No. of Perforations: Perforation Status: Perforation Status

Date:

Pro

Perforation Date: Producing Interval 

Top TMD (ft.):

Producing Interval 

Bottom TMD (ft.):

Perforation Phasing 

(deg.):

No. of Perforations: Perforation Status: Perforation Status

Date:

Pro

Perforation Date: Producing Interval 

Top TMD (ft.):

Producing Interval 

Bottom TMD (ft.):

Perforation Phasing 

(deg.):

No. of Perforations: Perforation Status: Perforation Status

Date:

Pro

Perforation Date: Producing Interval 

Top TMD (ft.):

Producing Interval 

Bottom TMD (ft.):

Perforation Phasing 

(deg.):

No. of Perforations: Perforation Status: Perforation Status

Date:

Pro

Perforation Date: Producing Interval 

Top TMD (ft.):

Producing Interval 

Bottom TMD (ft.):

Perforation Phasing 

(deg.):

No. of Perforations: Perforation Status: Perforation Status

Date:

Pro

Perforation Date: Producing Interval 

Top TMD (ft.):

Producing Interval 

Bottom TMD (ft.):

Perforation Phasing 

(deg.):

No. of Perforations: Perforation Status: Perforation Status

Date:

Pro

Perforation Date: Producing Interval 

Top TMD (ft.):

Producing Interval 

Bottom TMD (ft.):

Perforation Phasing 

(deg.):

No. of Perforations: Perforation Status: Perforation Status

Date:

Pro

Perforation Date: Producing Interval 

Top TMD (ft.):

Producing Interval 

Bottom TMD (ft.):

Perforation Phasing 

(deg.):

No. of Perforations: Perforation Status: Perforation Status

Date:

Pro

Perforation Date: Producing Interval 

Top TMD (ft.):

Producing Interval 

Bottom TMD (ft.):

Perforation Phasing 

(deg.):

No. of Perforations: Perforation Status: Perforation Status

Date:

Pro

Sheet B

Page of 
8000-FM-OOGM0004b Rev. 12/2015

Well API# 37- - - -

STIMULATION RECORD: STIMULATION INFORMATION/STAGE

Complete a separate record for each stimulation stage. Please insert additional copies of this sheet if additional rows are needed.

Stg #

Stage Top TMD

(ft.)

Stage Bottom

TMD (ft.)

Stimulation 

Begin Date

Stimulation End

Date

Average Pump 

Rate (bbls/min)

Max Breakdown 

Pressure (psig)

Average 

Treatment 

Pressure (psig) ISIP (psig) Propp

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

Sheet C

Page of 
8000-FM-OOGM0004b Rev. 12/2015

Well API# 37- - - -

STIMULATION RECORD: STIMULATION FLUID ADDITIVES/CHEMICALS

Please insert additional copies of this sheet if additional rows are needed.

Additive Information

Trade Name Vendor/Supplier Description

Chemical Information

CAS Number of Chemical Chemical Name % Mass in Stimulation Fluid

Sheet D

Page of 
8000-FM-OOGM0004b Rev. 12/2015

Well API# 37- - - -

TUBING INFORMATION

Size (O.D.) Grade Country of Origin Tubing Bottom TMD (ft.) Set Date Packer TMD (ft.)

Size (O.D.) Grade Country of Origin Tubing Bottom TMD (ft.) Set Date Packer TMD (ft.)

Size (O.D.) Grade Country of Origin Tubing Bottom TMD (ft.) Set Date Packer TMD (ft.)

COMMENTS

Sheet E

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