Page 1 of 3

CN

- O221 (Rev.0 7

- 1 3 ) RDA 1910 

## WELL HISTORY, WORK SUMMARY, AND COMPLETION OR RECOMPLETION REPORT

COMPLETE AND FILE WIT H IN 30 DAYS FROM THE DATE TOTAL DEPTH IS REACHED FOR EACH WELL DRILLED 

### API Well No. ______________

Field Name ______________

CSD CLASS ______________

(FOR STATE USE ONLY)



### WELL IDENTIFICATION Permit No.______

_ Operator :

______________________________________ _ Farm Name: ______________________ Well No._______ INITIAL PRODUCTION

Oil (BBL/Day):



### _________ Pumping Natural



### Gas (MCF/Day):



### _________ Flowing After Treatment



### Water (BBL

/Day):



### _________ GOR

_______________

Hours Tested: __________ Choke Size:__________

Pressure Tubing:__________ Shut

- In Flowing



### Casing (in psi):

__________ Shut

- In Flowing



### Disposition of Gas: Vented Fuel Sold



### Oil Gravity (*API):

__________ TYPE OPERATION

(Check One)



### New Well:

Work over:

Deepening: LOCATION 7 1⁄2’ quad ___________



### County ______________________

Carter Coordinates



### ______

_____

(Section) S E

Quad

Footage from Section Lines:

From S Line ______ From W Line_____

Lat: ___________ Long._____________

(D.F .)



### ELEVATION ___________ (Grou nd)



### ___________ (K.B

. )



### TOTAL DEPTH

Driller’s Log: ___________ Geophysical Log:___________ 

### PRODUCING INTERVAL

Formation Name(s) Interval(s)



### _____________ __________________________

_____________ __________________________

_____________ __________________________

_____________ __________________________

___ __________ __________________________

_____________ __________________________ OPERATIONAL DATES

Date Commenced 

### : __________ Date Drilling 

### :__________

Da t e Completed 

### : ___________ Date Placed In Operation

Date Plugged :



### ____________ _______________ (IF DRY HOLE) (IF PRODUCING, INJECTION, ETC.)

Date Shut

- In :

_________________ (IF SHUT

- IN OR OTHER TEMPARILY SUSPENDED OPERATION)



### DRILLING METHOD

Cable Tools Rotary Tools

from _________ to __________ Conventional

(Depths) from _______ to_________

Air (Depths)

from________ to ________

Contractor(s): ________________

______________________ Address ____________________ ______________________

____________________________ ______________________ 

### WE LL TREATMENT

(Check Applicable Boxes)

In open hole T hru perforation

Shot __________ qts. ___________ interval

Shot ______ ____ qts. ___________ interval

A cid __________ gals. __________ interval

Acid _____ _____ gals. __________ interval

Fracture: ________________________gals.

_____________interval

_________________ lbs/Sand

Fracture: ________________________gals

_____________interval

_________________ lbs/Sand

CASING RECORD

SIZE DEPTH SKS CEMENT CSG PULLED 

### TYPE(S) OF GEOPHYSICAL LOGS RUN:

(Electrical Induction, Sonic, Gamma Ray, Neutron, Density, etc.) 

### WELL PERMIT N O._______

_______ STATE OF TENNESSEE

DEPARTMENT OF ENVIRONMENT AND CONSERVATION

DIVIS I ON OF WATER RESOURCES

TENNESSEE OIL AND GAS PROGRAM

711 R

. S

. GASS BLVD

. NASHVILLE, TENNESSEE 37216Page 2 of 3

CN

- O221 (Rev.0 7

- 1 3 ) RDA 1910 

### TYPE OF COMPLETION

Shut In Producing

Dry Hole n/a n/a

Oil

Gas

Pressure Maintenance or Secondary Recover y

Water Injection

Gas Injection

Gas Storage:

Injection

- Extraction

Obs ervation SERVICE WELL

Saltwater Disposal

Water Supply

Observation Well

Other:

(If other describe type)

_____________________________

_____________________________



### NONCOMERCIAL SHOWS OF OIL AND GAS

Interval

(Depth

- Top Base) Formation Remarks

(Show of oil and/or gas, full up tests, Dist’s. Corps, ETC.)



### FORMATION RECORD

From To Rock Type

(Describe rock types and other materia ls

penetrated and record occurrences of oil,

gas and water from surface to total

depth) 

### From To Rock Type

(Describe rock types and other materials

penetrated and record occurrences of oil,

gas and water from surface to total

depth)Page 3 of 3

CN

- O221 (Rev.0 7

- 1 3 ) RDA 1910 

### Permit Operator Signature: ____________________________________________________________________

Affidavit

State of __________________________ Title ________________________

County of _________________________

Subscribed and sworn to before me this ____________ day of ________________, 20_______.

My commission expires _______________________

_______________________________________ Not ary Public Signature