Form 26 - Source Of Produced Water For Disposal
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FORM
26
State of Colorado
FOR OGCC USE ONLY
Rev 6/99
Oil and Gas Conservation Commission
1120 Lincoln Street, Suite 801, Denver, Colorado 80203 (303)894-2100 Fax:(303)894-2109
SOURCE OF PRODUCED WATER FOR DISPOSAL
This form must be completed for any new disposal site and for any change in sources of produced water for an existing
Complete the
disposal site.
Attachment Checklist
Oper OGCC
OGCC Operator Number: ____________________________
Contact Name and Telephone:
Chemical Analysis of fluid
Name of Operator: _____________________________________
___________________________________
Address: _____________________________________________
No:________________________________
City: __________________________ State: ____ Zip: _________
Fax:________________________________
OGCC Disposal Facility Number: ____________________________
Operator’s Disposal Facility Name: ____________________________ Operator’s Disposal Facility Number: ______
If more space is required,
Location (QtrQtr, Sec, Twp, Rng, Meridian): __________________________________________________________
attach additional sheet.
Address: _____________________________________________________________________________________
City: __________________________________ State: _____ Zip: ______________ County: ___________________
Add Source:
OGCC Lease No:_______________ API No:_____________________ Well Name & No:___________________________________
Operator Name:_______________________________________________________ Operator No:____________________________
Delete Source: Location: QtrQtr:__________ Section:_______ Township:_______ Range:_______ Producing Formation: _____________________
Analysis Attached?
Yes
No
Transported to disposal site via:
Pipeline
Truck
TDS:________________________
Add Source:
OGCC Lease No:_______________ API No:_____________________ Well Name & No:___________________________________
Operator Name:_______________________________________________________ Operator No:____________________________
Delete Source: Location: QtrQtr:__________ Section:_______ Township:_______ Range:_______ Producing Formation: _____________________
Analysis Attached?
Yes
No
Transported to disposal site via:
Pipeline
Truck
TDS:________________________
Add Source:
OGCC Lease No:_______________ API No:_____________________ Well Name & No:___________________________________
Operator Name:_______________________________________________________ Operator No:____________________________
Delete Source: Location: QtrQtr:__________ Section:_______ Township:_______ Range:_______ Producing Formation: _____________________
Analysis Attached?
Yes
No
Transported to disposal site via:
Pipeline
Truck
TDS:________________________
Add Source:
OGCC Lease No:_______________ API No:_____________________ Well Name & No:___________________________________
Operator Name:_______________________________________________________ Operator No:____________________________
Delete Source: Location: QtrQtr:__________ Section:_______ Township:_______ Range:_______ Producing Formation: _____________________
Analysis Attached?
Yes
No
Transported to disposal site via:
Pipeline
Truck
TDS:________________________
Add Source:
OGCC Lease No:_______________ API No:_____________________ Well Name & No:___________________________________
Operator Name:_______________________________________________________ Operator No:____________________________
Delete Source: Location: QtrQtr:__________ Section:_______ Township:_______ Range:_______ Producing Formation: _____________________
Analysis Attached?
Yes
No
Transported to disposal site via:
Pipeline
Truck
TDS:________________________
Add Source:
OGCC Lease No:_______________ API No:_____________________ Well Name & No:___________________________________
Operator Name:_______________________________________________________ Operator No:____________________________
Delete Source: Location: QtrQtr:__________ Section:_______ Township:_______ Range:_______ Producing Formation: _____________________
Analysis Attached?
Yes
No
Transported to disposal site via:
Pipeline
Truck
TDS:________________________
I hereby certify that the statements made in this form are, to the best of my knowledge, true, correct, and complete.
Print Name: _________________________________________ Signed: ________________________________________
Title:__________________________________________ Date:_____________________
OGCC Approved: ________________________________ Title:________________________________ Date:_____________
:
CONDITIONS OF APPROVAL, IF ANY
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