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Injection/Disposal/Commercial Disposal Wells Form 1073 Rev. 2016 IVSTRUCTIONS (Print or Type Using Black or Blue ink) A. Current Operator must attach Form 1012 report ' , ear of ,..ansor(1012 form must be current and up to date). B. Fill in the cornplete legal description below. C. Attach injection or disposal weirs Form 1002A.(note) D. List O.C.C. order / permit for injection / disposal. E. Attach MIT <1 year old (Commercial: <30 days).(note) NOTE: 1002A I MIT form filed online? Do I jOr attach. OKLAHOMA CORPORATION COMMISSION Oil & Gas Conservation Division Post Office Box 52000 Oklahoma City, Oklahoma 73152-2000 Transfer of Operator Single UIC Well OAC 165:10-5-10 DATE OF LAST MIT (within the last year): 01/03/17 API No. 35 037 29174 Surface Sec. 7 Location Ft. FSL 1980 Current Well Name & No. Twp. Ft. FWL 17N Rge. OTC P od. Unit No. 037 022198 7E 1/4 1/4 NW 1/4 NW 1/4 660 County Sarah Deere 7-7 Original Well Name & No. Sarah Deere 7-7 Creek OCC Order/Permit No. lUnit Name (if applicable) 140950021 N/A This form must be filed with the OCC within 30 days of Iransfer of the well. FEE: $25.00 OAC 165:5-3-1(b)(1)(N) (SEE BACK PAGE FOR PA'? 3 - ry ri CI INFORMATION)x—re DO NOT WRITE INSIDE THIS BOX.,..9 c) C.) 7-r , , 1\2 Tx• c..71 r - r- Use this form to transfer UIC wells only, Use Form 10731MIN to transfer 10 or more Lac . ransfer Date(MO/DAYNR): Well Classification (see back page) nINJ NCD OSINJ NGS LPGS no current operator is available, please sign the " diligence statement below. NOTE: Transfer will be denied if instructions A-E above are not followed. i 5 CUR ENT OP~ - E \C R -rl ATOR Q OCC/OTC No 20417 Name Southwest Petroleum Corporation Address 300 E Pine Street City Drumright State Zip OK 74030 FAX No./E-mail: I verify that I am the legal operator of record with authority to transfer operatorship of this well, that the facts presented herein are true and correct, and that l have completed this form and attached all documents as required by the above instructions. natory must b •sted o company' Form1 06B Operator's Agreement) Sign SZ - ri+ S-e u_Gr-as Name & Title (Print or Type) (AC) Phone davof 1Cult r Q(.11',1 Signed and VIOrhppfitori filn this 1 9. My Commissi Notary Publi NOTARVI polrl 5 rArE co , OKLAH MA vi OPERATOR 11 / 01 / 2016 OCC/OTC No. 23556 Name International Energy Company LLC Address 1801 E 71st Street City State Tulsa OK Zip 74136 FAX No./E-mail: hollie©iec-oil.com Being the new operator, as of the effective date of transfer, I accept the facts presented as being true and correct and accept the operational responsibility for the well on the described property. e on Richard Adrey Name & Title (Pdnt or Type) Signed and sworn tolbefore me trim My Commission Expires t 4 ;,' orm 1006B Operators Agreement) (918) 743-7300 (AC) Phone "&ti - 41.: 3 " mufirTP ,-, Public STASV 1 014VH 1- OmA ut fb c.) c) C, C., ci ro xe currem operator o- ' 4,, 111' !1....tf i t i &et . od Sc r INVI E§tcrrigerO l e 13°9°72 I verify under xa above well / lease and cated to obtain a signature. Signature Signed and sworn to beIore me this My Commission Expires: COMMISSION NO. Old0090 day of Notary Public FOR OCC USE ONLY Department: Received Approved Date Surety MAY 1 2 2017 u IC 1 2 7017 Well Records 1 KAY 15 ZOIT WELL RECORDS APPROVED By processing this Form 1073 , the Oklahoma Corporation Commission has approved the contents thereof as to form only. The Oklahoma Corporation Commission does not warrant that the ,c.:ts provideO by the operator are true. Transfer is not effective until approved by the Well Records Department. rti 7,5 C::, r—t• 3 rs1
