Get OK Form 1012 2020-2024

OKLAHOMA CORPORATION COMMISSION Oil & Gas Conservation Division Underground Injection Control Department Post Office Box 52000 Oklahoma City, Oklahoma 73152-2000 AMENDED FORM THIS IS A COPY OF THE ONLINE VERSION Form 1012 Rev. 2014 Annual Fluid Injection Report OAC 165:10-5-7(b)1 January 1 thru December 31, WELLS ON THIS REPORT HAVE MULTI STRING INJECTION Instructions 1 2 3 4 5 File additional second pages if well count exceeds ten (10) File one (1) copy for each enhanced recovery project, disposal or LPG storage well by April 1st for previous year's activity. Fresh water is defined as water containing less than 10,000 mg/1 TDS or less than 5,000 PPM Chlorides. If well was plugged, enter the plugging date as shown on Form 1003C. Complete heading, all questions which pertain to your well(s), and mail Form 1012A to the above address. Current Operator Current Operator No. Listed Operator by UIC (If Different from Current due to pending 1073I) Listed Operator No. Current Operator Address Current Operator Telephone No. City State Zip Code 1 TYPE OF WELL Enhanced Recovery Disposal Commercial First Six Months LPG Full Report 2 TYPE OF FLUID INJECTED / DISPOSED Saltwater Gas LPG Brackish Water Fresh Water (If checked, answer question 6.) 2a How was injection or disposal measured? Calculated Metered 3 What was the total annual injected or disposed volume of fluids? Barrels MCF (If more than one well, use back page where directed) 4 What was the average daily well head pressure? 5 What is the packer depth? PSI (If more than one well, use back page where directed) (If more than one well, use back page where directed) 6 If all or part of injected fluid is fresh water, from which source is it derived? Well (depth feet) Pond Where is the source located? Stream Section, Other Township, Range 7 This section is for Disposal / LPG only (Individual Well) (Location) Section Township Formation 7a Range Depth County Authorized by OCC Order or Permit # API Number 8 This section is for Enhanced Recovery only. (Project Basis) Order No.(s) / Permit No.(s) (Location) Section OTC Production Unit No. Township Range County(or counties if more than one) Pool Name Formation 8a (Use additional back pages as needed) List all API Numbers on the back of this form where directed. 9 Date of last Mechanical Integrity Test 9a List or describe any repairs or testing performed on any or all wells listed on this report. Depth (If project basis, attach additional page) (attach additional sheet if necessary) 10 This is a summary overview of previously answered questions and must be completed. A. Enter the well(s) name and number; B. Enter well(s) API No.; C. Enter well(s) legal location; D. Enter well(s) most current order / permit number; E. Enter well(s) packer depth; F. Enter monthly data for daily average pressure rate and total monthly BBLS/MCF injected; G. At the bottom of each numbered column, enter annual injected volumes. 1 2 3 4 5 A. Well Name & No. B. API No. C. Legal Location D. Order / permit No. E. Packer Depth PSI Bbls/MCF PSI Bbls /MCF PSI Bbls /MCF PSI Bbls / MCF PSI Bbls / MCF F. January February March April May June July August September October November December G. Total annual Injection 6 7 8 9 10 Well Name & No. API No. Legal Location Order / Permit No. Packer Depth PSI Bbls/MCF PSI Bbls /MCF PSI Bbls /MCF PSI Bbls / MCF PSI Bbls / MCF January February March April May June July August September October November December Total Annual Injection Verification of Information I declare that I have knowledge of the contents of this report and am authorized by my organization to make this report, which was prepared by me or under my supervision and direction with the data and facts stated herein to be true, correct and complete to the best of my knowledge and belief. Signature Title of Authorized Agent Name (Typed or Printed) Address Phone.