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Report On Results On Plugging Well (Oil & Gas Form 4) - Washington State Department Of Natural Resources

REPORT ON RESULTS

ON PLUGGING WELL

(Oil & Gas Form 4)

Permit no. ________________

This report must be filed with the Oil & Gas Supervisor, Department of Natural Resources, Division of Geology and Earth

Resources, MS 47007, Olympia, WA 98504-7007, within 15 days after plugging has been completed.

You are hereby notified of the completion of the plugging of a well known as: ____________________________________

Well no: ____________ in ________ of section _____ T ____ N R _______ . County: _________________________

Latitude/longitude (decimal degrees to four places minimum) __________________________________________________

Total depth is _________ feet. Spud date: __________ . Date plugging: began ____________ completed ____________ .

Attach a detailed narrative account of the manner in which work was performed. Include descriptions of the nature and

quantities of materials used in plugging; the depths and lengths of the various plugs; records of any tests or measurements

made; amount, size, and depth of all casing left in the well; volume and gravity of mud-laden fluid used; pressures retained in

mudding; and a complete record of any shooting done.

Person in charge of plugging: ______________________________________________ Phone: ______________________

Address: ______________________________________________________________ Email: _____________________

City/State/Zip _____________________________________________________________ Fax: _____________________

I hereby swear or affirm that the information given herewith is a complete and correct record of the well and all work done on

it so far as can be determined from available records.

Subscribed and sworn to before me

on this ________________ day of __________________

_______________________________________________

Place

_______________________________________________

My commission expires: ___________________________

Notary Public

Signature: _______________________________________

Name: __________________________________________

Position: ________________________________________

Representing (company or operator): ____________________________________________________________________

Address: _________________________________________________________ Phone: __________________________

City/State/Zip: ____________________________________________________ Email: __________________________

Oil & Gas Form 4

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Revised 8/12/2013jmr

Report On Results On Plugging Well (Oil & Gas Form 4) - Washington State Department Of Natural Resources