Form 139 Form 139 Application for Operations / Report on Wells

Osage Form 139 OMB Control No. 1076-XXXX

Revised May 2013 Expires: XX/XX/XXX

U.S. DEPARTMENT OF THE INTERIOR, BUREAU OF INDIAN AFFAIRS, OSAGE AGENCY

813 Grandview, P.O. Box 1539, Pawhuska, Oklahoma, 74056

(918) 287-5740 FAX: (918) 287-5786

Date ____________________________

APPLICATION FOR OPERATION OF REPORT ON WELLS

_________________________________________________________________________________________________________

(Commencement money paid to whom) (Date) (Amount)

Well No. ______________ is located ________ ft. from N / S (CIRCLE ONE) line and ________ ft. from E / W (CIRCLE ONE) line

_________________________________ ___________________________ ______________________ Osage Co., Oklahoma

surface

derrick floor

(1/4 Section & Section No.) (Township) (Range)

The elevation of the above sea level is _________ ft. Latitude___________ & Longitude __________

USE THIS SIDE TO REQUEST AUTHORITY FOR WORK

(Three copies required)

USE THIS SIDE TO REPORT COMPLETED WORK

(One copy required)

Notice of intention to:

Drill ( )

Plug ($15 fee required) ___________( )

Deepen or plug back ( )

Convert ( )

Pull or alter casing ( )

Formation Treatment ( )

Other ( )

Details of Work

Drilling application will state proposed TD & Horizons to be tested. Show size and length of casings to be used. Indicate proposed mudding, cementing and other work.

Plugging applications shall set forth reasons for plugging & detailed statement of proposed work.

Plugging will not commence until 10 days following approval date unless authority granted for earlier commencement.

A $15.00 plugging fee is also required with each application to plug.

Well production prior to work

_______ bbls oil ___________bbls wtr/24 hrs

T.D. ______________ B.H.L. (if applicable)___________

Zone:_________________________________________

Casing Plan:

I understand that this plan of work must receive approval in writing of the BIA Osage Agency before operations may be commenced.

Lessee:_________________________________________

Signature:_______________________________________

Title:___________________________________________

Address:________________________________________

Telephone:______________________________________

Character of well (oil, gas or dry)___________________

Subsequent report of:

Conversion ( )

Formation Treatment ___________( )

Altering Casing ( )

Plugging Back ( )

Plugging ( )

Details of Work & Results Obtained

Work commenced ________________________ 20______

Work completed __________________________ 20 ____

(Continue on reverse side if needed)

_________________________________________________

This block for plugging information only

CASING RECORD

Size	In hole when started	Amount recovered	If parted
			Depth	How

ORIGINAL TOTAL DEPTH

_________________________________________________

Lessee: _____________________________________________

By:_____________________________________________

Signature

Subscribed and sworn to before me this day ____ of ________ 20____

My commission expires:______ _________________________

Notary public

Paperwork Reduction Act (PRA) Statement: This information is collected to meet reporting requirements and is subject to the PRA. An agency may not request nor sponsor, and a person need not answer a request for information that does not contain a valid OMB control no. A response to this request is required to obtain a benefit. The public reporting burden for this form is estimated to average 8 hours, including the time for reviewing the instructions, gathering and maintaining data, and completing and reviewing the form. Send comments on the burden estimate or any other aspect of this form to Information Collection Clearance Officer–Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240.