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UPI STATES ENVIRONMENTAL PflOTECTION AGENCY ~ Form Approved <br />WASHINGTON, DC 20660 OMB No. 3040-0093 <br />\e,E pq COMPLETION REPORT FOR BRINE DISPOSAL, APprovel expires 9-3086 <br />HYDROCARBON STORAGE, OR ENHANCED RECOVERY WELL <br />NAME AND ADDRESS OF E%ISTING PERMITTEE NAME AND ADDRESS OF SURFACE OWNER <br />LOCATE WELL AND OUTLINE UNIT ON <br />SECTION PLAT - 640 ACRES <br />N <br />Iw <br />-+~t <br />I I I <br />I I I <br />-TTT TT <br />-~~~ <br />I I I -I-~--~ <br />I I I <br /> <br />- I ~~ ~ I <br />-LPL <br />I I I 1-Ll <br />i l l <br />Estimated Fracture Pressure <br />of Injection Zone <br />Am¢ipated Daily Injection Volume (Bblsl Injection Interval <br />Average Maximum Feet to Feet <br />Average <br />s <br />Type of Injection Flwd /Check the appropriate blocklsll <br />^ Sah Water ^ Braddsh Water ^ fresh Water <br />^ L'puid Hydrocarbon ^ Olhar <br />Drilling Began j Date Well Compltttetl <br />I Date Drilling Completed <br />4essure PSI Depth to Bottom of Lowermost freshwater Formation <br />Maximum IFeetl <br />Lease Name ~ Wetl Number <br />Name of Injection Zone <br />Permeability o11n(eaion Zone <br />Porosity of Injection Zane <br />HOLE <br />I OD Sire I W VFr - Gratle -New or Usad I Depth I Sacks I Class I Depth I Ba Diameter I <br />WIRE LINE LOGS. LIST EACH <br />Intervals <br />I Complete Attachments A - E listed on the reverse. 1 <br />CERTIFICATION <br />/certify under the penalty of law that /have persona//y examined and am familiar with the in/ormation <br />submitted in this document and all attachments and that, based on my inquiry o/ those individuals <br />immediate/y responsible /or obtaining the in/ormation, l believe that the information is true, accurate, <br />and comp/ate. /am aware that there are signi/icant penahies forsubmitting false information, including <br />the possibility o/fine and imprisonment. (Re% 40 CFR 144.32J. <br />~ NAME AND OFFICL4L TITLE (P/ease type or prim/ <br />DATE SIGNED <br />SURFACE LOCATION DESCRIPTION <br />'A OF 'A OF '/• SECTION TOWNSHIP RANGE <br />LOCATE WELL IN TWO DIRECTIONS FROM NEAREST ONES OF QUARTER SECTION AND DflILUNG UNIT <br />Surtece <br />Location, h, from IN/SI _ Line of quaver section <br />E ^ Brine Disposal ^ Individual <br />^ Enhanced Recovery ^ Area <br />^ Hydrocarbon Storage Number of Wells <br />EPA Form 7520-T 0 (2-841 <br />