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fOlm R OYep. UMG /YO. L(M/-UNL. AppIOYe/ GI(1/ICS 9-.1Vb0 <br />RED STATES ENVIRONMENTAL PROTECTION AGENC <br />A WASHINGTON, DC 20460 <br />~l'1rEPA WELL REWORK RECORD <br />NAME AND ADDRESS OF PERMRTEE NAME AND ADDRESS OF CONTRACTOR <br />LOCATE WELL AND OUTLINE UNR ON <br />SECTKIN PLAT -640 ACRES <br />~ I I I ~ I I I ~ <br />S <br />Sixe I Depth I Sects <br /> SURFACE LOCATION DESCRIPTION <br /> '/• OF 'h OF +R SECTION TOWNSHIP RANGE <br /> LOCATE WELL IN TWO DIRECTIONS FROM NEAREST LINES OF QUARTER SECTION AND DRIWNG UNIT <br /> Surtace <br /> Location _ h. from (N/51 _ Line of quaver section <br /> and _ h. from -Line of uaner section <br /> WELL ACTIVfTY Total Depth Before Rework TYPE OF PERMIT <br /> ^ Brine Disposal ^ Individual <br />E ^ Enhanced Recovery <br />Tmal Depth Aher Rework ^ Area <br /> ^ Hydrocarbon Storage Number of Wells <br /> Lease Name Date Rework Commenced Well Number <br />Date Rework Completed <br />WELL CASING RECORD -BEFORE REWORK <br />4 PertorMions <br />TYpe From To <br />Acid or Fracture <br />I WELL CASING RECORD -AFTER REWORK I/ndicete Addrrions end Chenaes On/vl I <br />Size I Depth I Saris <br />DESCRIBE REWORK OPERATIONS IN DETAIL <br />From I To <br />CERTIFICATION <br />Acitl or Fracture <br />WIRE LINE LOGS. LIST EACH TYPE <br />l certi/y under the penalty o/law that l have personalty examined and am familiar with the in/ormation <br />submitted in this document and a/l attachments and that based on my inquiry of those individuals <br />immediately responsible /or obtaining the information, l be//eve that the information is true, accurate, <br />and complete. lam aware that there are signi/icant penalties forsubmitting/else information, including <br />the possibi/ity of /ine and imprisonment. (Rel. 40 CFR 144.32/. <br />I NAME AND OFFICL4L TITLE IP/ease type Or prinrl I SIGNATURE <br />DATE SIGNED <br />EPA Forrn 7520-T2 (2-B4) <br />