7520-10 Completion Report for Brine Disposal, Hydrocarbon Storag

OMB No. 2040-0042

Approval Expires 4/30/07

United States Environmental Protection Agency
Washington, DC 20460

COMPLETION REPORT FOR BRINE DISPOSAL,
HYDROCARBON STORAGE, OR ENHANCED RECOVERY
Name and Address of Existing Permittee

Name and Address of Surface Owner

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

TYPE OF PERMIT

Brine Disposal

Individual

Enhanced Recovery

Area

Hydrocarbon Storage

S

Injection Interval

Average

Feet

Maximum

Average

Brackish Water

Liquid Hydrocarbon
Date Drilling Began

Lease Name

Fresh Water

to Feet

Depth to Bottom of Lowermost Freshwater
Formation (Feet)

Maximum

Type of Injection Fluid (Check the appropriate block(s))

Well Number

Name of Injection Zone

Other
Date Well Completed

Permeability of Injection Zone

Date Drilling Completed

Porosity of Injection Zone

CEMENT

CASING AND TUBING
OD Size

Number of Wells ____

Anticipated Daily Injection Volume (Bbls)

Anticipated Daily Injection Pressure (PSI)

Salt Water

Estimated Fracture Pressure
of Injection Zone

Wt/Ft - Grade - New or Used

Depth

Sacks

INJECTION ZONE STIMULATION
Interval Treated

HOLE
Class

Depth

Bit Diameter

WIRE LINE LOGS, LIST EACH TYPE

Materials and Amount Used

Log Types

Logged Intervals

Complete Attachments A -- E listed on the reverse.

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 7520-10 (Rev. 8-01)

Signature

Date Signed

ATTACHMENTS

A.

Present a schematic or other appropriate drawing of the surface and subsurface
construction details of the well as built.

B.

Describe the method and results of mechanical integrity testing.

C.

Present the results of that portion of those logs, test, and cores which specifically
relate to (1) underground sources of drinking water and the confining zone(s) and
(2) the injection and adjacent formations.

D.

Present the status of corrective action on defective wells in the area of review.

E.

Provide to EPA, with the completion report, one final print of all geophysical logs
run.

PAPERWORK REDUCTION ACT
The public reporting and record keeping burden for this collection of information is estimated to average 4 hours
per well. Burden means the total time, effort, or financial resource 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; develop, acquire, install, and utilize technology and systems for the purposes of collecting,
validating, and verifying information, processing and maintaining information, and disclosing and providing
information; 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. 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, 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 7520-10 Reverse