7520-14 Plugging and Abandonment Plan

OMB No. 2040-0042

Approval Expires 4/30/07

United States Environmental Protection Agency
Washington, DC 20460

PLUGGING AND ABANDONMENT PLAN
Name and Address of Facility

Name and Address of Owner/Operator

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

TYPE OF AUTHORIZATION

E

WELL ACTIVITY

Individual Permit

CLASS I

Area Permit

CLASS II
Brine Disposal

Rule

Enhanced Recovery

Number of Wells ____

Hydrocarbon Storage
CLASS III

S

Lease Name

Well Number

CASING AND TUBING RECORD AFTER PLUGGING
SIZE

WT (LB/FT)

TO BE PUT IN WELL (FT)

METHOD OF EMPLACEMENT OF CEMENT PLUGS

TO BE LEFT IN WELL (FT)

HOLE SIZE

The Balance Method
The Dump Bailer Method
The Two-Plug Method
Other

CEMENTING TO PLUG AND ABANDON DATA:

PLUG #1

PLUG #2

PLUG #3

PLUG #4

PLUG #5

PLUG #6

Size of Hole or Pipe in which Plug Will Be Placed (inches)
Depth to Bottom of Tubing or Drill Pipe (ft.)
Sacks of Cement To Be Used (each plug)
Slurry Volume To Be Pumped (cu. ft.)
Calculated Top of Plug (ft.)
Measured Top of Plug (if tagged ft.)
Slurry Wt. (Lb./Gal.)
Type Cement or Other Material (Class III)
LIST ALL OPEN HOLE AND/OR PERFORATED INTERVALS AND INTERVALS WHERE CASING WILL BE VARIED (if any)
From

To

From

To

Estimated Cost to Plug Wells

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 7520-14 (Rev. 8-01)

Signature

Date Signed

PLUG #7

Paperwork Reduction Act Notice
The public reporting and record keeping burden for this collection of information is
estimated to average 19.5 hours annually for operators of Class I wells, 6 hours
annually for operators of Class II wells, and 8 hours annually for operators of Class III
wells. Burden means the total time, effort, or financial resources expended by
persons to generate, maintain, retain, or disclose or provide information to or for a
Federal agency. This includes the time needed to review instructions; adjust the
existing ways to comply with any previously applicable instructions and requirements;
train personnel to be able to respond to the collection of information; search data
sources; complete and review the collection of information; and, transmit or otherwise
disclose the information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid
OMB control number. The OMB control numbers for EPA’s regulations are listed in
40 CFR Part 9 and 48 CFR Chapter 15.
Please send comments on the Agency’s need for this information, the accuracy of the
provided burden estimates, and any suggested methods for minimizing respondent
burden, including the use of automated collection techniques to Director, Office of
Environmental Information, Collection Strategies Division, U.S. Environmental
Protection Agency (2822), Ariel Rios Building, 1200 Pennsylvania Ave., NW.,
Washington, DC 20460; and to the Office of Information and Regulatory Affairs, Office
of Management and Budget, 725 17th Street, NW., Washington, DC 20503, Attention:
Desk Officer for EPA. Please include the EPA ICR number and OMB control number
in any correspondence.

EPA Form 7520-14 Reverse