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® Afu+ittl of IFrvaNn Ga • • <br />MmrL PidMiuf <br />a~aoucw NgnN~i <br />~'~ Oil, Gu and Salt Ruources Act <br />Annual Report of Monthly Injection <br />for the year <br />Form 6 To: the Minister of Natrual Resources <br />Operator: Tel. # Fax # <br />Address <br />T/~fs form only applies to fluid injection jor secondary recovery. <br />All iniection wells must be reported and all iniecton must be reported. If space is insufficient attach additional farmc <br />Well Name: Source Pool: <br />Township: Source Formation: <br />Tract Lot Concession Fluid Type: <br />Wel] Licence #: Injection Formation: <br />Well Status -Mode': Injection Pool: <br />Injection Permit #: <br />- As of lice. s t - wcnve, suspenpeq aoanaonea, tesnng, potential <br />Description of fltrid treatment prior to injection: <br />Month . Volume Injected (m') Average Daily <br />Injection Pressure <br />(kPag at wellhead) Days on <br />Injection Injection Rate <br />(ms/day) <br />Jan <br />Feb <br />Maz <br />Apri] <br />May <br />June <br />July <br />Aug <br />Scp <br />Oct <br />Nov <br />Dec <br />Total <br />The undersigned certifies that the above information is complete tied accurate and he/she has authority to bind the operator. <br />Name: Date: <br />Signature: Position Held: <br /> <br />