7520-12 Well Rework

OMB No. 2040-0042

Approval Expires 4/30/07

United States Environmental Protection Agency
Washington, DC 20460

WELL REWORK RECORD
Name and Address of Permittee

Name and Address of Contractor

State

Locate Well and Outline Unit on
Section Plat - 640 Acres

County

Permit Number

Surface Location Description

N

____ 1/4 of ____ 1/4 of ____ 1/4 of ____ 1/4 of

Section ____ Township ____ Range ____

Locate well in two directions from nearest lines of quarter section and drilling unit
Surface
Location ____ ft. frm (N/S) ____ Line of quarter section
and ____ ft. from (E/W) ____ Line of quarter section.
W

WELL ACTIVITY

E

Total Depth Before Rework

Brine Disposal
Enhanced Recovery

TYPE OF PERMIT
Individual

Total Depth After Rework

Hydrocarbon Storage

Area
Number of Wells ____

Date Rework Commenced
Lease Name

Well Number
Date Rework Completed

S

WELL CASING RECORD -- BEFORE REWORK
Casing
Size

Cement
Depth

Sacks

Perforations
Type

From

Acid or Fracture
Treatment Record

To

WELL CASING RECORD -- AFTER REWORK (Indicate Additions and Changes Only)
Casing
Size

Cement
Depth

Sacks

Perforations
Type

From

Acid or Fracture
Treatment Record

To

WIRE LINE LOGS, LIST EACH TYPE

DESCRIBE REWORK OPERATIONS IN DETAIL
USE ADDITIONAL SHEETS IF NECESSARY

Log Types

Logged Intervals

Certification
I certify under the penalty of law that I have personally examined and am familiar with the information submitted in this document and all
attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the
information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the
possibliity of fine and imprisonment. (Ref. 40 CFR 144.32)
Name and Official Title (Please type or print)

EPA Form 7520-12 (Rev. 8-01)

Signature

Date Signed

PAPERWORK REDUCTION ACT
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minimizing respondent burden, including the use of automated collection techniques to Director, Collection Strategies
Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave., NW., Washington, D.C. 20460. Include
the OMB control number in any correspondence. Do not send the completed forms to this address.

EPA Form 7520-12 Reverse