85-15-7 (4/09)--28a

NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION

DIVISION OF MINERAL RESOURCES

PAGE 1 OF 2

PRINT OR TYPE IN BLACK INK

WELL DRILLING AND COMPLETION REPORT

For instructions on completing this form, visit the Division's website at www.dec.ny.gov/energy/205.html or contact your local Regional office.
FOR DEPARTMENT USE ONLY
Reviewed by

Date

WELL NAME AND NUMBER

Well Type

API WELL IDENTIFICATION NUMBER

31 -

WELL OWNER (Full Name of Organization or Individual as registered with the Division)

TYPE OF REPORT
Interim

TYPE OF WELL
New

Final

TYPE OF WELL BORE

Vertical
Directional

Existing

Horizontal

If the well is a directional or sidetrack, also submit a complete directional survey

TYPE
OF
OPERATION
WELL TYPE (Test data, if available, must be noted on page 2 of this form)
D
Drill
Plug Back
Gas Production
Geothermal
Brine
Dry Hole
Injection
R
I
Deepen
Convert
Oil Production
Stratigraphic
Storage
Other (Specify)
L
FLUIDS
PRODUCED
OR
INJECTED
TYPE
OF
COMPLETION
L
Oil
Gas
Brine
Fresh Water
Single
Multiple
L
N
G

LPG

Other (Specify)

Brine Disposal

Other (Specify)

7 MINUTE QUAD NAME

QUAD SECTION

A
N
D LOCATION DESCRIPTION
Surface
0'
G
Top of Target Interval
E
Bottom of Target Interval
N
Bottom Hole
E
TVD
R
A PRODUCING FORMATION(S)
L

0'

Decimal Latitude (NAD83)

___ ___ . ___ ___ ___ ___ ___ ___

Decimal Longitude (NAD83)

___ ___ . ___ ___ ___ ___ ___ ___

___ ___ . ___ ___ ___ ___ ___ ___

___ ___ . ___ ___ ___ ___ ___ ___

___ ___ . ___ ___ ___ ___ ___ ___

___ ___ . ___ ___ ___ ___ ___ ___

___ ___ . ___ ___ ___ ___ ___ ___

___ ___ . ___ ___ ___ ___ ___ ___

TMD

I
N COUNTY
F
O
R TOWN
M
A
T FIELD/POOL NAME
I
O
N
DRILLERS TD (ft.) LOGGERS TD (ft.)
TVD
TMD

DEEPEST FORMATION PENETRATED

DRILLING CONTRACTOR(S)

For vertical wells, use TMD to record depths

DATE DRILLING COMMENCED

DRILLED WITH CABLE TOOLS (TMD)

Month
Day
DATE DRILLING COMPLETED

From
ft. to
DRILLED WITH ROTARY TOOLS (TMD)

ft.

From
ft. to
ROTARY DRILLING FLUID

ft.

Year

Month
Day
Year
DATE FINAL COMPLETION/RECOMPLETION
Month

Day

PLUG BACK TO (ft.) KICKOFF DEPTH (ft.)

TVD
TMD

Water

Year

TVD
TMD

TMD

Air

Mud

ELEV. (ft.)

Topo

DATUM (ft.)

DF

Survey
KB

GL

If the well was NOT plugged back completely with cement, also file a Plugging Report (form 85-15-8) to show the details of the plug back
LIST ALL WIRELINE LOGS RUN--SUBMIT TWO (2) COPIES OF EACH

WELL CORED

Gamma Ray

Resistivity

Density

Neutron

Mud

Directional

Induction

Temperature

Caliper

Sonic

Others (Specify)
CASING
STRINGS

C
A
S
Drive Pipe or Conductor
I
N
G Surface or Water

Sidewall

PIPE
SIZE

GRADE/WT.

Yes

Conventional

CUTTINGS COLLECTED FOR STATE

No

HOLE
SIZE

No

NEW OR
USED

CASING

SLURRY
WT. (ppg)

YIELD
(ft.3/sx)

Yes
DEPTHS SET (TMD)
CENTRALIZERS

BASKETS

P
Intermediate
R
O
G Production
R
A
M Liners
CEMENT
DATA

C
E Drive Pipe or Conductor
M
E
Surface or Water
N
T
Intermediate
D
A
T Production
A
Liners

CLASS/TYPE
OF CEMENT

NUMBER
OF SACKS

VOLUME
(ft.3)

CEMENT
TOP (TMD)

W.O.C.
(hrs.)

I hereby affirm under penalty of perjury that information provided on this form is true to the best of my knowledge and belief. False statements
made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law.
Printed or Typed Name of Authorized Representative
Signature

Title

Date

WELL DRILLING AND COMPLETION REPORT

85-15-7 (4/09)28a

ATTACH ADDITIONAL INFORMATION AS NECESSARY

API WELL IDENTIFICATION NUMBER

WELL NAME AND NUMBER

31 P
R
E
C
O
M
P
L
E
T
I
O
N

C
O
M
P
L
E
T
I
O
N

TYPE OF TEST
(dst, bail, etc.)
T
E
S
T

P
R
O
D
U
C
T
I
O
N

R
E
C
O
R
D

ft. to

ft.

ft. to

ft.

D
A
T PERFORATED INTERVALS (TMD)
A
ft. to

NO. OF SHOTS

PERFORATED INTERVALS (TMD) Continued

ft. to

ft.

ft. to

ft.

ft. to

ft.

ft. to

ft.

ft. to

ft.

ft. to

ft.

ft. to

ft.

ft. to

ft.

ft. to

ft.

ft. to

ft.

ft. to

ft.
GAS TEST
Build Up

T
E DURATION OF
S TEST
hrs.
T
PRODUCTION
Oil
bpd

NO. OF SHOTS

DETAILS: type and volume of materials, rates, breakdown psi, average treatment psi, isip, etc.

FORMATION TESTED

B
E
D
R
O
PC
EK
N
E
T
R
A
T
E
D

WELL COMPLETED OPEN HOLE (TMD)

ft. to
ft.

ft.

D
A
T
A

U
N
C
O
N
S
O
L
I
D
A
T
E
D

FLUID TYPES AND AMOUNTS PRODUCED AND OTHER DATA

ft. to
ft.
COMPLETION EQUIPMENT: List tubing, packer, rods, pump, bridges, etc.; note sizes and depths

O
F
F
O
R
M
A
T
I
O
N
S

DURATION
OF TEST (hrs.)

ZONES TESTED (TMD)

ZONES TREATED (TMD)

S
T
I
M
U
L
A
T
I
O
N

PAGE 2 OF 2

FLOWING TEST DATA

Choke
in.
Water
bpd

Tubing

Gas
mcfpd

Open Flow
Drawdown

OIL TEST
Pump

Casing
S.I. Tubing
psi
psi
psi
GAS MEASURED BY
Orifice
Pitot

DEPTH IN FEET

DEPTH IN FEET

(TVD)

(TMD)

FORMATION
NAME

---------

INITIAL SHUT-IN PRESSURE

Flow

Surface
Bottom Hole

psi.
psi.

S.I. Casing
S.I. Time
psi
hrs.
TEST STARTING DATE
Estimated

DESCRIBE ROCK TYPE AND RECORD QUANTITY AND TYPE OF

FRESH WATER, BRINE, OIL AND GAS

Ground Surface (Elevation)