Form Ogb-1c - Application For Permit To Inject Fluids - State Oil And Gas Board Of Alabama

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STATE OIL AND GAS BOARD OF ALABAMA

OGB-1C

Application for Permit to Inject Fluids

_______________________________________

____________________________________________

Permit Number

(

)

API Number

To be filled in by Board

Form OGB-1C, Rev. 07/13

Disposal operations

Enhanced recovery operations

(File in triplicate)

Name of Operator ___________________________________________________________ Date ____________________________________

Address _______________________________________________ City _____________________ State ____________ Zip _______________

1. Well name and number

2. County

(give footage from nearest section or offshore tract lines)

Section-Township-Range or Tract

Well

Location

Latitude

Longitude

▪

(NAD27)

(actual surface)

4. Original permit no. (if converted)

5. Field

6. Elevation (ground)

7. Nearest oil, gas or other class II well (if less than 1,320 ft)

Permit no.

Name

Distance (ft)

8. Date of OGB conceptual approval (Step 1)

9. Approximate date injection to begin

10. Proposed injection fluid(s)

11. Source(s) of fluids

12. Estimated daily injection volume

Min.

Max.

13. Proposed injection formation

14. Formation fracture pressure

15. Anticipated injection pressure

gradient (psi/ft)

Name

Perfs

Avg.

Max.

16. Base of fresh water (<10,000 mg/L TDS)

17. Base of significant aquiclude

Formation

Subsea Depth

Formation

Subsea Depth

18. Last pressure test

19. If witnessed by agent of board, give name

20. Person to contact regarding

Phone Number

this application

Fax Number

E-mail Address

Remarks:

___________________________________________________

________

Executed this the _______ day of __________

, 20 __

Signature

________________________________________

Before me, the undersigned authority, on this day personally appeared

known to me to be the person

whose name is subscribed to the above instrument, who being by me duly sworn on oath states that he/she is duly authorized to make the above report and that

he/she has knowledge of the facts stated therein, and that said report is true and correct.

_______

____________________

_________

Subscribed and sworn to before me this

day of

, 20

_____________________________________

SEAL

_____________________

Notary Public in and for

____________________