Form Ogc-3 - Application For Permit To Drill, Deepen Or Plug Back Form

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STATE OF MISSOURI

FORM OGC-3

GEOLOGICAL SURVEY PROGRAM

APPLICATION FOR PERMIT TO DRILL, DEEPEN OR PLUG BACK

APPLICATION TO DRILL

DEEPEN

PLUG BACK

FOR AN OIL WELL

OR GAS WELL

NAME OF COMPANY OR OPERATOR

DATE

ADDRESS

CITY

STATE

ZIP CODE

DESCRIPTION OF WELL AND LEASE

NAME OF LEASE

WELL NUMBER

ELEVATION (GROUND)

WELL LOCATION

(GIVE FOOTAGE FROM SECTION LINES)

___________ ft. from

North

South section line

___________ ft. from

East

West section line

WELL LOCATION

LATITUDE

LONGITUDE

COUNTY

___________

Sec. ____

Township ____ North

Range ____

East

West

__________

NEAREST DISTANCE FROM PROPOSED LOCATION TO PROPERTY OR LEASE LINE

FEET

__________

DISTANCE FROM PROPOSED LOCATION TO NEAREST DRILLING, COMPLETED OR APPLIED – FOR WELL ON THE SAME LEASE

FEET

PROPOSED DEPTH

DRILLING CONTRACTOR, NAME AND ADDRESS

ROTARY OR CABLE TOOLS

APPROX. DATE WORK WILL START

NUMBER OF ACRES IN LEASE

_________

NUMBER OF WELLS ON LEASE INCLUDING THIS WELL, COMPLETED IN OR DRILLING TO THIS RESERVOIR

_________

NUMBER OF ABANDONED WELLS ON LEASE

_________

NO. OF WELLS PRODUCING

IF LEASE PURCHASED WITH ONE OR MORE WELLS DRILLED, FROM WHOM PURCHASED?

_________

INJECTION

_________________

NAME

_________

INACTIVE

_________________________________________________________

ADDRESS

_________

ABANDONED

SINGLE WELL

BLANKET BOND

ON FILE

STATUS OF BOND

AMOUNT $ ___________

ATTACHED

REMARKS: (IF THIS IS AN APPLICATION TO DEEPEN OR PLUG BACK, BRIEFLY DESCRIBE WORK TO BE DONE, GIVING PRESENT PRODUCING/INJECTION ZONE AND EXPECTED NEW

INJECTION ZONE; USE BACK OF FORM IF NEEDED)

PROPOSED CASING PROGRAM

APPROVED CASING – TO BE FILLED IN BY STATE GEOLOGIST

AMOUNT

SIZE

WT/FT

CEMENT

AMOUNT

SIZE

WT/FT

CEMENT

I, the Undersigned, state that I am the _________ of the _________ (Company), and that I am authorized by said company to make