8000

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COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF ENVIRONMENTAL PROTECTION

OFFICE OF OIL AND GAS MANAGEMENT



# Completion Repor t DEP USE ONLY

Site ID Primary Facility ID

Client ID Sub F acility 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 Infor mation, ”

Doc. No. 800 0

- FM

- OOGM0132 ” and instructions.



### W ELL INFORMAT ION

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

37

- - - - Well Farm Name : Well No. :

Address : LAT

- ° ׳ ״ NAD 83 Project Number : Serial No. :

LONG

- ° ׳ ״

City : State : Zip Code : Municipality : County :

Telep hone 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

W ater S ources Withdrawal Start Date Withdrawal End Date Volume (Gallons)

1.

2.

3.

4.

5.

Total Gallons from W ater 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 B ase Fluid(s) (Other): /



### STIMULATION/PRODUCTION INFORMATION (WELL)

Radioactive tracers used :

Yes No If “Yes”, specify tracer(s): Commencement Date: Completion Date:

Open Flow (mcfd ) : O pen F low Measurement Method : Surface Pressure (psig ) : S urface P ressure 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 Rep ort 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 of8000

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### 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, each notch should be reported as a

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: Producing Formation(s):

Perforation Date: Producing Interval

Top TMD (ft.): Producing Interval

Bottom TMD (ft.): Perforation Phasing

(deg.): No. of Perforations: Perforation Status: Perforation Status

Date: Producing Formation(s):

Perforation Date: Producing Interval

Top TMD (ft.): Producing Interval

Bottom TMD (ft.): Perforation Phasing

(deg.): No. of Perforations: Perforation Status: Perforation Status

Date: Producing Formation(s):

Perforation Date: Producing Interval

Top TMD (ft.): Producing Interval

Bottom TMD (ft.): Perforation Phasing

(deg.): No. of Perforations: Perforation Status: Perforation Status

Date: Producing Formation(s):

Perforation Date: Producing Interval

Top TMD (ft.): Producing Interval

Bottom TMD (ft.): Perforation Phasing

(deg.): No. of Perforations: Perforation Status: Perforation Status

Date: Producing Formation(s):

Perforation Date: Producing Interval

Top TMD (ft.): Producing Interval

Bottom TMD (ft.): Perforation Phasing

(deg.): No. of Perforations: Perforation Status: Perforation Status

Date: Producing Formation(s):

Perforation Date: Producing Interval

Top TMD (ft.): Producing Interval

Bottom TMD (ft.): Perforation Phasing

(deg.): No. of Perforations: Perforation Status: Perforation Status

Date: Producing Formation(s):

Perforation Date: Producing Interval

Top TMD (ft.): Producing Interval

Bottom TMD (ft.): Perforation Phasing

(deg.): No. of Perforations: Perforation Status: Perforation Status

Date: Producing Formation(s):

Perforation Date: Producing Interval

Top TMD (ft.): Producing Interval

Bottom TMD (ft.): Perforation Phasing

(deg.): No. of Perforations: Perforation Status: Perforation Status

Date: Producing Formation(s):

Perforation Date: Producing Interval

Top TMD (ft.): Producing Interval

Bottom TMD (ft.): Perforation Phasing

(deg.): No. of Perforations: Perforation Status: Perforation Status

Date: Producing Formation(s):

Perforation Date: Producing Interval

Top TMD (ft.): Producing Interval

Bottom TMD (ft.): Perforation Phasing

(deg.): No. of Perforations: Perforation Status: Perforation Status

Date: Producing Formation(s):

Perforation Date: Producing Interval

Top TMD (ft.): Producing Interval

Bottom TMD (ft.): Perforation Phasing

(deg.): No. of Perforations: Perforation Status: Perforation Status

Date: Producing Formation(s):

Perforation Date: Producing Interval

Top TMD (ft.): Producing Interval

Bottom TMD (ft.): Perforation Phasing

(deg.): No. of Perforations: Perforation Status: Perforation Status

Date: Producing Formation(s):

Perforation Date: Producing Interval

Top TMD (ft.): Producing Interval

Bottom TMD (ft.): Perforation Phasing

(deg.): No. of Perforations: Perforation Status: Perforation Status

Date: Producing Formation(s):

Perforation Date: Producing Interval

Top TMD (ft.): Producing Interval

Bottom TMD (ft.): Perforation Phasing

(deg.): No. of Perforations: Perforation Status: Perforation Status

Date: Producing Formation(s):

Sheet B



### Page of8000

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### 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) Proppant Type Proppant Size(s)

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



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### Well API # 37

- - - -

STIMULATION RECORD: STIMULATION FLUID ADDIT I VES /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 of8000

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### 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



### Page of