KANSAS CORPORATION COMMISSION OIL & GAS CONSERVATION DIVISION

Form U·1 Jutf 2006

Form must be Typed Form must be Signed

All blanks must be Filled APPLICATION FOR INJECTION WELL

Disposal ~

Enhanced Recovery: ~ ~~1 Repressuring

~] Watertlood

r-: Tertiary

Date: January__!,19Q8 .

Operator License Number: -~~9-~~~- ----·­

. Sample Oil, LLC Operator. - ----·---·· ... ___ _

Address: J 30 8-!....M.9rket .

Wichita, KS 6720~. -··-·---

Contact Person: .l_M. §..§l!'!IP!~.- .. -·-- - - ---·-- - ---Phone: .. ~~:~.~-~.:.~~9 .. 9. -· ...

Check One: 17-: Old Well Being Converted ~-1 Newly Drilled Well

Surface Elevation: .J.970~- feet Well Total Depth: 2300' feet

Permit Number: (to be assigned by ~CC)·---·--··-·-·-­

API Number: 15-207-99999

Well Location 2J East

SW NW SE Sec. 22 _ Twp. n_ s. R. 14._ 0 wes1

1650 Feet from SOUTH Section Line

_.2..,.3_..1~0 _ _ , Feet from EAST Section Line

Lease Description: S/2 Sec 22 and SE/4 Sec 21-23S-14E

Lease Name: S_m_it_h __ _ OWWO 'A'#1 _ Well Number:-·------· ......

Field Name: .£her~kee Basin Coal A_r~~ ......... ..... ·--··-··-··--· ·-·---

County: Woodson

Deepest Usable Water

Formation: Alluvium

Depth to Bottom of Formation: __ 1_5' _ ____________ .. ____ ___ - -···-- ·-·

0 Weil to be Drilled

Plug Back Depth: _N_A__ feet

Datum of top of injection formation: 2230' feet (reference mean sea level)

Injection Formation Description: Name top I bottom pert I open hole depth

Arbuckle . Open Hple at 223.Q_. ____ __ to -~30Q... .. __ .. .,. feet

---- -·-·--·-·---· ·· - --.. -·-···--- -·-- I - - --- ----- at ............ . ....... -·-to .... ----- - - - · feel

List of Wells/Facilities Supplying Produced Saltwater or Other Fluids Approved by the Conservation Division: (attach additional sheets if necessary)

Lease Operator

1. -~~_rnple OJl,_L_~G

2. _§am~Oil.l...LLC .

II

3 .. --··------· . · -· --· -·

Producing Formation

2. ___ _

Lease/Facility Name

Smith ----------·--- ------ - - - --- ------Jones

Strata Depth

Lease/Facility Description

.§12 22-:?~:.11.~--- -·---·- ..... SE/4 21-23-14~----

Well I[) & Spot Location

#1 SW SE SE 22-23-14E

#2A SE SE'SE 21 -23-1 E

4A SW NW SE 21-23-14E

Total Dissolved Solids (if available)

1800 to 1 ~9.Q. ·- feet J.?.!..Q9Q. ~9!!. mg/I

to --·- feet

3. ______ ... . ... ........... ... .. ... __ . . ·· -· · to ........ - - - fee\ .. .. . ......... . .. .. mg/I

Maximum Requested Liquid Injection Rate: ~.QQQ ......... _. __ bbls I day; or

Maximum Requested Gas lnjeclion Rate: __ ·-- ____ sci I day. Type of Gas:----~---------

Maximum Requested Injection Pressure: 100 ' . - ·-· - · ... . . .. .. ........ ps1g

Mail to: KCC - Conservation Division, 266 N Main St., Ste 220, Wichita, Kansas 67202-1513

SAMPLE

Well Completion

Type: [Z] Tubing & Packer 0 Packertess

Conductor Surface

Size 8 5/8"

Setting Depth 25'

Amount or Cement 8 sx

Top of Cement O'

Bottom of Cement 25'

If Alternate II cementing, complete the following:

Page Two

D Tubingless

Intermediate Production

41/2"

2230'

I 150 sx

O'

2230'

Tubing

2 3/8"

2180'

Form U-1 November 2 01 1

Perforations I D.V. Tool at _N_o_n_e ______ feet, cemenled 10 -------- feet wilh -------- sx.

Tubing: Type Lined Seal-Tite

Packer: Type AD-1 Tens ion

Annulus Corrosion Inhibitor: Type _K_C_L_T_r_e_a_te_d_ W_a_te_r ________ _

List Logs Enclosed: Cement Bond Log

Well Sketch (To sketch installation, darken the appropriate Jines, Indicate cement, and show depths.)

/..j 'IJ. '1 .p ~t>d u<.:f° 11

OY\ C. il 5 ; l'\~ @ 2.236' w/1s-on

Static fluid level Is _7_2_0_'___ feet below surface.

Grade J-55

Depth _2_1_8_0_'---------- - ----

Concenlralion _5_0/c_o ______________ _

~~11

.sv\'".fat.L c:.as i"'!l® is-' w/f~r

ON 2230fZ.3DO'

SAMPLE

Page Three

Offset Operators, Un/eased Mineral Owners and Landowners acreage

(Attach additional sheets if necessary)

Name:

Acme Oil, Co.

John Q . Public

Jane Doe

Gusher Oil, Inc.

R. Smith (landowner)

Legal Description of Leasehold:

N/2 Sec. 22-23-14E

NW/4 Sec. 23-23-14E

SW/4 Sec 23-23-14E

N/2 Sec 27-23-14E

S/2 Sec 22-23-14E

I"""'' ,.,,;fy Iha! ~'""'-"" ~d• ""''""'I~ ~d '°"'cf lo~' be'1 of m2~L tZ Applicant or Duly Authorized Ager;~

Form U-1 November 201 t

Subscribed and sworn before me this 1st day or November _2_0_1_1 _ _

.,,.JJ.etfiUt (I V{ruclf

Instructions:

1. Fully complete application, including page 4 (plat map) showing subject well and all known oil, gas and input wells, including wells being drilled,

inactive wells. or dry holes, within one-half mile. Show lease names and operators or unleased mineral rights owners or all lands within one-hall mile.

Show well numbers and elevations of producing !ormalion tops.

2. Al1ach some type of log (drillers log, electric log, etc.).

3. Attach some type of verification of cementing for surface casing, longstring, 0.V. tool, perforations, etc. (Cement ticket and job log, bond log, etc.)

4. Attach Affidavit of Notice.

5. Fill in schematic drawing of subsurface facilities including: size, setting depth, amount of cement, measured or calculated tops of cement for each of

surface, intermediate (if any) and production casing; size and setting depth of tubing and packer; geological zone of injection showing top and bottom

of injection interval.

6. The original and one copy of the application and all attachments shall be mailed to the State Corporation Commission, Conservation Division.

7. Deliver or mail one (1) copy of the application to the landowner on whose land the injection well is located and to each operator or lessee of record

and each unleased mineral rights owner within one-half mile of the applicant well.

8. Approval of lhis application, ii granted, is valid only as long as there are no substantial changes in operation set forth in the application. A substantial

change requires the approval of a new application. No injection well may be used without prior written authori:tation.

9. All application fees must accompany the application.

SAMPLE

Page Four

Plat and Certificate of Injection Well Location and Surrounding Acreages

Operator: Sample 011, LLC LocationofWell: SW NW SE Sec. 22-23-14E

Form U-1 November 2011

Lease: Smith _1_6_5_0 ____________ feet from D N I [l] s Line or Section

Well Number: OWWO 'A' #1

County: Woodson

_2_3_1_0 ________ ___ _ feet from [l] E I 0 W Line of Section

Sec. _2_2 ___ _ 23 S. R. 14 Twp. - ---- - - - -- il] East D West

Plat

Show the following information: applicant injection well, all producing wells, inactive wells, plugged wells, and other wells within a one-half mile radius, all lease boundar·

ies, lease operators, unleased mineral rights owners, well numbers, and producing wells producing formation tops.

f • -7tO ; 21-------·- ...... 22 .

S':.a.~p/ .. 611->t.uci A· I : 0:1 :

"/' ~ 4 ~ :·1-,,·· A"f/~~

iA • _.,,,

l.t applicant well ,6.

D & A well -<?­

plugged producer 1'

2.7

producing well •

other injection well ,i.

water supply well t.

plugged Injection well jli

temporary abandoned well •

The undersigned hereby certifies that he I she is a duly authorized agent for ,.5# ltl D J.e..- t), '/ / ,LL L­I

shown herein is true, complete and correct to the best of his I her knowledge.

, and that all of the information

SAMPLE

Affidavit of Notice Served

Re: Application for: - ~-~_r:r:_pJ~ . .QB!_!:~--------

Page Five FormU·1 July 2006

--------·--- -------·----------Well Name: -~-~i_t~ C}'('!'!!_O 'A' #1 ____________ _ Legal Location: _ SVIJ._J:}'!'!_ SE Se_<?.: __ ?~:~-~~-4-~- ____ - ---------------_

The undersigned hereby certi1icates thal he I she is a duly authorized agent for the applicant, and that on the day _J_~_t_ of ____ ~~~:1~ry __ --- ·--- -- -

2008 _ _ ___ __ . a true and correct copy of the application referenced above was delivered or malled to the following parlies:

Note: A copy of this affidavit mus/ be served as a parl at the application.

Name

Acme Oil, Co.

John Q. Public

John Doe

Gusher Oil, Inc.

R. Smith (landowner)

Address (Attach additional sheets if necessary)

c/o Banker's Trust, Anytown, KS 66000

Box 82, SmaHtown, KS 67000

789 S. Bend, Box 456, Centerville. KS 67200

PO Box 82, Bigtown, KS 67200

123 S. M:aple, Anytown, KS 66000

I further attest lhat notice ot the tiling of this applicalion was published in the --~~~~-Cente~:~~-- --· -----··- ....... --·- __ _ _ _ ·- ··· . the ofticial county publication

of Woodson ____ county. A copy of the attidav1t ot this publicaJion is attached.

Signed this __ _!~t. __ January day of ___ .. . ___ _ 2008

---r·------·- - -----·-----·----· -· ---.--------· -------- ------ - -Applicant of Duly Authorized Agent

Subscribed and sworn to before me this -~--- day or ~~n~~_ry __________ _____ ... ________ . ?__g_Q~----

- -----------------------------· -·---· ----·-· -------·--·-- ·----·--· Notary Public

My Commission Expires:

Protests may be filed by any party having a valid interest in the application. Pelilions for protests shall be in writing and shall clearly identify the name and address of lhe

protestant and the title of the application. The peti tion shall include a clear and concise statement of the· ~irect and substantial interest of the protestant in the proceedings.

including the manner in which the protestant may be affected, and the nature, extent, character and ll:"lunds of the protest. Protestants shall serve the protest upon lhe

applicant by mail or personal service at the same time or before the protestant files the protest with the ~nservation Division. Protests must be tiled within 15 days of lhe

oublication notice of the applical1on.

Mail to: KCC - Conservation Division, 266 N Main St., Ste 220, Wichita, Kansas 67202-1513

SAMPLE

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