CN-O221(Rev.07-13) Page 1 of 3 RDA 1910

WELL HISTORY,WORK SUMMARY,AND COMPLETIONOR RECOMPLETION REPORT

COMPLETE AND FILE WITHIN 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 ___________ (Ground) ___________ (K.B.)

TOTAL DEPTH

 Driller’s Log: ___________ Geophysical Log:___________

PRODUCING INTERVAL

Formation Name(s) Interval(s)

_____________ __________________________

_____________ __________________________

_____________ __________________________

_____________ __________________________

_____________ __________________________

_____________ __________________________

OPERATIONAL DATES

Date Commenced: __________ Date Drilling:__________

Date 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 ____________________ ______________________

____________________________ ______________________

WELL TREATMENT

 (Check Applicable Boxes) 

In open hole Thru perforation

Shot __________ qts. ___________ interval 

Shot __________ qts. ___________ interval 

Acid __________ 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 NO.______________ STATE OF TENNESSEE

DEPARTMENT OF ENVIRONMENT AND CONSERVATION

DIVISION OF WATER RESOURCES

TENNESSEE OIL AND GAS PROGRAM

711 R. S. GASS BLVD.

NASHVILLE, TENNESSEE 37216
CN-O221(Rev.07-13) Page 2 of 3 RDA 1910

TYPE OF COMPLETION

 Shut In Producing 

Dry Hole n/a n/a

Oil

Gas

Pressure Maintenance or Secondary Recovery

 Water Injection

 Gas Injection

Gas Storage:

 Injection-Extraction

 Observation

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 materials 

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)
CN-O221(Rev.07-13) Page 3 of 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 _______________________ 

 

_______________________________________

Notary Public Signature