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UNITED STATES ENVIRONMENTAL PROTECTI ENC1 III I II I II ~ II IIII II <br />WASHINGTON, DC 10480 <br />:~-~ PA PLUGGING AND ABANDONMENT PLAN sss <br />NAME AND ADDRESS OF FACILITY 7 a NAME AH,D (ADDRESS OF OWNER/OPERATOR p <br />~"~ : ~ ~"/~ ~~ 0 ~bC . ~vG~~; Vy C) ~ P~ ~ I wvi~~ far <br /> <br />LOCATE WELL AND OUTLINE UNR ON <br />SERION PLAT <br />Bl0 ACRES STATE COUNTY PERMIT NUMBER <br />- <br />N SURFACE LOCATION DESCRIPTION <br />_ 1/4 of _1/4 of _ 1/6 of _ 1/4 of Seetion_ Townehip_ Fianpa_ <br /> I LOCATE WELL IN TWO DIRERION$ FROM NEAREST 11NE5 OF QUARTER SERION AND DRILLING UNn <br />Surleca <br />Location-h. hom (N/SI-Line d pwher Itection <br /> TTT end-h. Irom E -Lined uener section <br /> L ACTIVITY <br />WE <br /> <br />E TYPE OF ALJTHORQATION <br />^ Individual Permit L <br />^ CLASS I <br />W <br />~_ ^ Area Permit <br />^ Rul. ^ CLASS II <br />^ Brina Disposal <br /> <br /> <br />t'~" <br />Number of Wells - O Enhsnced Recovery <br />^ Hydiocarbon Storage <br />^ CLASS III <br /> <br /> 5 Lsase Name Wall Number <br />LASING AND TUBING RECORD AFTER PLUGGING METHOD OF EMPLACEMENT OF CEMENT PLUGS ' <br />^ The Balanee Method <br />SIZE YVTILB/FT) TO BE PUr IN WELL IFII 0 BE LEFT IN WELL IFTI HOLE S¢E ^ The Dump Bailer Method <br /> ^ The Two-Plug Method <br /> ^ Other <br /> <br /> <br />CEMENTING TO PLUG AND ABANDON DATA: PLUG e1 PLUG e2 PLUG a3 PLUG e6 PLUG e5 PLUG e6 PLUG e7 <br />Sixs of Hols or Pipe in which Plu Will Be Plecad linchesl <br />Depth to Bosom of Tubl or Drlll Pipe Ih.l <br />Sacks d Csment To Be Used (each plug) <br />Slurry Vdume To ee Pumped Icu. h.l <br />CekuletW Top d Plup Ih.l <br />Mnmred Tap of Plu (il uq h.l <br />Slurry Nh. (Lb./Gel.) <br />T Lemont ar OtMr Mnerlel Cleo III <br />LIST ALL OPEN HOLE AND/OR PERFORATED INTERVALS AND INTERVALS WHERE LASING WILL BE VARIED la enYl <br />From To Fram To <br /> <br /> <br /> <br /> <br /> <br />EnimetM Coat to Plug Wells <br />CERTIFICATION <br />l certify under the penalty of law that l have personally examined end am familiar with the information <br />submitted in this document and all attachments and that, based an my inquiry of those individua/s <br />immediately responsib/e for obtaining the information, l believe that the information is true, accurate, <br />end comp/ate. /em aware that there are significant pens/ties farsubmitting false information, including <br />the possibi/ity of fine and imprisonment. (Rel. 40 CFR 144.32) <br />NAME AND OFFICIAL TITLE /Pl~ese rYW Or pinrl SIGNATURE DATE SIGNED <br />FormA nrorda LIMB NO iwO~00ai Aapre.e~ Expires'-]U-9ti <br />EPA Forth 7620-14 <br />