85-15-7 (4/09)--28a NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION PAGE 1 OF 2

 DIVISION OF MINERAL RESOURCES 

PRINT OR TYPE IN BLACK INK

WELL DRILLING AND COMPLETION REPORT

For instructions on completing this form, visit the Division's website at www.dec.ny.gov/energy/205.html or contact your local Regional office.

FOR DEPARTMENT USE ONLY

Reviewed by Date Well Type

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WELL NAME AND NUMBER API WELL IDENTIFICATION NUMBER

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WELL OWNER (Full Name of Organization or Individual as registered with the Division)

TYPE OF REPORT TYPE OF WELL TYPE OF WELL BORE

 Interim Final New Existing Vertical Directional Horizontal

If the well is a directional or sidetrack, also submit a complete directional survey

TYPE OF OPERATION WELL TYPE (Test data, if available, must be noted on page 2 of this form)

Drill Plug Back Gas Production Geothermal Brine Dry Hole Injection Brine Disposal

Deepen Convert Oil Production Stratigraphic Storage Other (Specify)

FLUIDS PRODUCED OR INJECTED TYPE OF COMPLETION

Oil Gas Brine Fresh Water Single Multiple

LPG Other (Specify) Other (Specify) 

71⁄2 MINUTE QUAD NAME QUAD SECTION

LOCATION DESCRIPTION Decimal Latitude (NAD83) Decimal Longitude (NAD83)

Surface 0' 0' ___ ___ . ___ ___ ___ ___ ___ ___ ___ ___ . ___ ___ ___ ___ ___ ___

Top of Target Interval ___ ___ . ___ ___ ___ ___ ___ ___ ___ ___ . ___ ___ ___ ___ ___ ___

Bottom of Target Interval ___ ___ . ___ ___ ___ ___ ___ ___ ___ ___ . ___ ___ ___ ___ ___ ___

Bottom Hole ___ ___ . ___ ___ ___ ___ ___ ___ ___ ___ . ___ ___ ___ ___ ___ ___

TVD TMD

PRODUCING FORMATION(S) DEEPEST FORMATION PENETRATED DRILLING CONTRACTOR(S)

For vertical wells, use TMD to record depths

COUNTY DATE DRILLING COMMENCED DRILLED WITH CABLE TOOLS (TMD)

Month Day Year From ft. to ft.

TOWN DATE DRILLING COMPLETED DRILLED WITH ROTARY TOOLS (TMD)

Month Day Year From ft. to ft.

FIELD/POOL NAME DATE FINAL COMPLETION/RECOMPLETION ROTARY DRILLING FLUID

Month Day Year Water Air Mud

DRILLER’S TD (ft.) LOGGER’S TD (ft.) PLUG BACK TO (ft.) KICKOFF DEPTH (ft.) ELEV. (ft.) Topo Survey

TVD TVD TVD TMD TMD TMD TMD DATUM (ft.) DF KB GL

If the well was NOT plugged back completely with cement, also file a Plugging Report (form 85-15-8) to show the details of the plug back

LIST ALL WIRELINE LOGS RUN--SUBMIT TWO (2) COPIES OF EACH WELL CORED No Yes

Gamma Ray Resistivity Density Neutron Mud Sidewall Conventional

Directional Induction Temperature Caliper Sonic CUTTINGS COLLECTED FOR STATE

Others (Specify) No Yes

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CASING HOLE PIPE GRADE/WT. NEW OR DEPTHS SET (TMD)

STRINGS SIZE SIZE USED CASING CENTRALIZERS BASKETS

Drive Pipe or Conductor

Surface or Water

Intermediate

Production

Liners

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CEMENT CLASS/TYPE NUMBER SLURRY YIELD VOLUME CEMENT W.O.C.

DATA OF CEMENT OF SACKS WT. (ppg) (ft.3

/sx) (ft.3) TOP (TMD) (hrs.)

Drive Pipe or Conductor

Surface or Water

Intermediate

Production

Liners

I hereby affirm under penalty of perjury that information provided on this form is true to the best of my knowledge and belief. False statements

made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law.

Printed or Typed Name of Authorized Representative

Signature Title Date
85-15-7 (4/09)–28a WELL DRILLING AND COMPLETION REPORT PAGE 2 OF 2

ATTACH ADDITIONAL INFORMATION AS NECESSARY

WELL NAME AND NUMBER API WELL IDENTIFICATION NUMBER

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TYPE OF TEST ZONES TESTED (TMD) DURATION FLUID TYPES AND AMOUNTS PRODUCED AND OTHER DATA (dst, bail, etc.) OF TEST (hrs.)

ft. to ft.

ft. to ft.

ft. to ft.

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COMPLETION EQUIPMENT: List tubing, packer, rods, pump, bridges, etc.; note sizes and depths WELL COMPLETED OPEN HOLE (TMD)

ft. to ft.

PERFORATED INTERVALS (TMD) NO. OF SHOTS PERFORATED INTERVALS (TMD) Continued NO. OF SHOTS

ft. to ft. ft. to ft.

ft. to ft. ft. to ft.

ft. to ft. ft. to ft.

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ZONES TREATED (TMD) DETAILS: type and volume of materials, rates, breakdown psi, average treatment psi, isip, etc.

ft. to ft.

ft. to ft.

ft. to ft.

ft. to ft.

ft. to ft.

ft. to ft.

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FORMATION TESTED GAS TEST Open Flow OIL TEST INITIAL SHUT-IN PRESSURE

Build Up Drawdown Pump Flow Surface psi.

Bottom Hole psi.

DURATION OF FLOWING TEST DATA

TEST Choke Tubing Casing S.I. Tubing S.I. Casing S.I. Time

hrs. in. psi psi psi psi hrs.

PRODUCTION GAS MEASURED BY TEST STARTING DATE

Oil Water Gas Orifice Pitot Estimated

bpd bpd mcfpd

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DEPTH IN FEET

(TVD)

 DEPTH IN FEET 

 (TMD)

 FORMATION 

NAME

DESCRIBE ROCK TYPE AND RECORD QUANTITY AND TYPE OF

FRESH WATER, BRINE, OIL AND GAS

0 0 - - - - - - - - - Ground Surface (Elevation) 

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