Fillable Form Ogb-11 - Report Of Well Plugging printable pdf download

Form Ogb-11 - Report Of Well Plugging

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STATE OIL AND GAS BOARD OF ALABAMA

OGB-11

Report of Well Plugging

___________________________________________

____________________________________________

Form OGB-11, Rev. 07/13

Permit Number

API Number

(File in triplicate)

Partial

Permanent

Name of Operator ____________________________________________________________________________________________________

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

3. Well Location

(actual surface)

4. Field (if wildcat, so state)

5. Pool or injection horizon

6. Type of well (oil, gas, class II, dry hole, etc.)

7. Perforations

8. Person to contact

Phone number

regarding this form

Fax number

E-mail address

RESULTS OF PLUGGING

Permission to plug and procedure authorized by ____________________________________________ Date ___________________________

(Oil & Gas Board Agent)

Date plugging operations began _______________________ Drilling contractor ___________________________________________________

Date partial plugging operations completed ____________________ Workover contractor ___________________________________________

Date permanent plugging operations completed* _____________________ Cementing contractor _____________________________________

Date steel plate affixed on casing stub.

Give full details of plugging accompanied by a wellbore schematic. When describing the cement plugs include the following: number of sacks,

yield, class, top and bottom depths of plug. (See instructions for additional requirements.)

Operation witnessed by Agent of the Board

Yes

If yes, give name of Agent _________________________________

__________

________

___________________________________________________

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

_____________________________________

_____________________

Notary Public in and for

SEAL

________________________________