## 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