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 fo rm, visit the Division's website at www.dec .ny.gov/energy/205.htmlor contact your local Regional office. FOR DEPARTMENT USE ONLY

Reviewed by Date Well Type

D R I L L L N G
A N D
G E N E R A L
I N F O R M A T I O N WELL NAME AND NUMBER API WELL IDENTIFICATION NUMBER 

## 31 -

- - - WELL OWNER (Full Name of Organization or I ndividual 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 Strati graphic 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) D EEPEST 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 COMPLETI ON/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 filea Plugging Report (form 85-15-8)to show the details ofthe 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 C A S I N G
P R O G R A M 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

C E M E N T
D A T A 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 provi ded on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Cl ass A misdemeanor pursuant to Section 210.45 of the Penal Law. Printed or Typed Name of Authorized Representative Signature Title Date85-15-7 (4/09)–28a 

# WELL DRILLING AND COMPLETION REPORT PAGE 2 OF 2 ATTACH ADDITIO NAL INFORMATION AS NECESSARY WELL NAME AND NUMBER API WELL IDENTIFICATION NUMBER 

### 31 -
- - - P R E C O M P L E T I O N T

E S T 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.

C O M P L E T I O N D

A T A 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.

S T I M U L A T I O N D

A T A 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. P R O D U C T I O N T

E S T FORMATION TESTED GAS T EST 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

R E C O R D
O F
F O R M A T I O N S
P E N E T R A T E D U

N C O N S O L I D A T E D 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)

B E D R O C K