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I orm AAUrovetl. OM6 No. 7000-OD<?. <br />.: F PA <br />VAME PND ADDRESS OF PERMRTEE <br />UNU L U J IA i w c n vinan,..•. ^'DC 70460 <br />WASHINGTON, <br />WELL REWORK RECORD <br />NAME AND ADDRESS OF CONTRACTOR <br />SUAFACE IOLATION DESCRIPTION RANGE <br />'h OF Y. OF 'A SECTION TOWNSNIP <br />LOCATE WELL IN 1W0 DIRECTIONS FROM NEAREST LINES OF QUARTER SECTION AND DRILLING UNR <br /> Surface <br />Location _ h. from IN/SI <br />-Line of Buener seebn <br /> and _ h. from E _ line o1 uaner section <br />Total Depth Before Rework <br />TYPE OF PERMR <br /> WELL ACTIVITY <br /> ^ Brine Disposal ^ Individu9l <br />E O Enhanced Recovery <br />Total Depth Aher Rework ^ Area <br />Number of Wells - <br /> ^ Hydrocarbon Storage <br /> Date Rework Commenced Well Number <br /> Lease Name <br /> Date Rework Completed <br />To <br />CASING RECORD-AFTER REWORK <br />Ce en1 Penor <br />. _ ~ ~..... From <br />~~~~ <br />DESCRIBE REWORK OPERATIONS IN <br />..,.... r.nrtrnNAl SHEETS IF NECE: <br />CERTIFICATION <br />end <br />LINE <br />Acitl « Fracture <br />Acid or Fra«uro <br />I cattily under the penalty of law that l have personally examined and am familiar with the information <br />submitted in this document and all attachments and that, based on my inquiry of those individuals <br />immediately responsible for obtaining the information, l believe that The information is true, accurate, <br />andcomplere. lam aware that there are signilicanr gene/ties for submitting false information, including <br />the possibility of line and imprisonment. (Ref. 40 CfR 144.32). <br />SIGNATURE I DATE SIGNED <br />NAME ANO OFFICWL TRLE /Please type or prrntl <br />LOCATE WELL AND OUTLINE UNR ON <br />SECTION PLAT -640 ACRES <br />