North Carolina Department of Environment and Natural Resources 

Division of Energy, Mineral, and Land Resources 

Energy Section - Oil and Gas Program 

1612 Mail Service Center, Raleigh, NC 27699-1612 

Phone: (919) 707-9220 

Fax: (919) 715-8801 

Email: DEMLRoilandgas@ncdenr.gov

Page

Form 

12 

Rev 03/2015 Document ID:

Date:

Received by:

Well Drilling Report

Permittee Name:

Company Name:

Address:

City:

Phone:

Fax:

Email:

State: Zip:

API Number:

Lease/Well 

Name:

Well Number:

County:

Nearest Town/

City:

Well Site Ingress/

Egress Location:

Oil & Gas Program Use Only

Type of Well:

Oil

Gas

Dry

* Other

Strat.

Spud Date:

T. D. Date:

Dates:

Measured Depth:

True Vertical Depth:

Total Depth of Well (feet):

Ground:

Kelly Bushing:

Elevation (feet):

New Well

Workover

Deepen

Plugback

Recomplete

Type of Well Operation:

Required Attachments: Permittee DEMLR-OGP

Cement Ticket

Wireline Logs

Drilling Log

Pressure Tests

Formation Integrity Test

Wellbore Survey

Drill Stem Test

Core/Cuttings

Method of Drilling:

Cable/Rotary

Service Rig

Rotary: Air Fluid

15A NCAC 05H .1623

* Describe Other Type of Well:
Form 12 - Well Drilling Report Permittee Name:

Page

API Number:

Casing Program:

Wellbore 

Diameter

(inches)

Wellbore 

Depth

(feet)

Casing 

Diameter

(inches)

Casing 

Depth

(feet)

Casing/

Liner Top

(feet)

Casing 

Weight per 

Foot

(pounds)

Cement 

Bottom

(feet)

Cement 

Top

(feet)

CBL

Conductor

Surface

Intermediate

Production

Liner

Tubing

Cement Information:

Type of Cement Cement Additives Cement Density Cement Volume 

(sacks) Cement Yield

Conductor

Surface

Intermediate

Production

Liner

Number of Casing 

Collars Location of Collars Method of Determination

Conductor

Surface

Intermediate

Production

Liner

Casing Collars:
Form 12 - Well Drilling Report Permittee Name:

Page

API Number:

Drilling Fluid Information:

Air Drilling

(Yes or No)

Fluid Drilling

(Yes or No) Type of Fluids

Conductor

Surface

Intermediate

Production

Liner

Formation Log Intervals and Test Zones:

Measured Depth (feet) Check if applicable: 

Formation Name Top Bottom DST Cored Methane 

Encountered*

Number of Centralizers Description of Location

Conductor

Surface

Intermediate

Production

Liner

Tubing

Wellbore Equipment:
Form 12 - Well Drilling Report Permittee Name:

Page

API Number:

Number of 

Engines Type of Engine 

Horsepower of 

Engine Less than 

750 hp (Yes or No)

Max. Site 

Rated Horsepower

Hours of 

Use at the 

Well Site 

Air Quality Emissions Reporting:

* If methane is encountered in a formation other than the target formation, describe below how the drilling, casing, 

and cementing was modified (if needed) in response:

Describe any "other" zones encountered during drilling activities including depth method of determination: 

("other" include groundwater, brine, anomalous pressure, corrosive fluids, lost circulation, and fluids capable of annular flow) 
Form 12 - Well Drilling Report Permittee Name:

Page

API Number:

Summary of Events:

Any other information required per permit conditions:
Form 12 - Well Drilling Report Permittee Name:

Page

API Number:

Date:

Title:

Signature:

Print Name:

This form must be signed by the permittee or an authorized agent of the permittee.

Yes No Have all notifications related to Form 11 been submitted to the Department in accordance with 

15A NCAC 05H .1600?

Notifications to the Department:

The following items are required with the submittal of the Well Drilling Report. The items may be attached by email or hardcopy. If 

attached by email, provide the file name.

Cement Tickets

File Name(s) if attached by email:

Wireline Log(s)

Drilling Log(s)

Pressure Test(s)

Formation Integrity Test(s)

Wellbore Inclination Survey

Drill Stem Test(s)

Directional Wellbore Survey