1003 1003c Form
User Manual: 1003C
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OKLAHOMA CORPORATION COMMISSION TO SEND THIS FORM TO THE OCC, PLEASE USE THE APPROPRIATE DISTRICT OFFICE ADDRESS (ON THE BACK OF THIS FORM) TYPE OR USE BLACK INK API NO. Form 1003/1003C Rev. 2017 PLUGGING RECORD OTC PROD. UNIT NO. OAC 165:10-11-7 (PLEASE SEE INSTRUCTIONS ON BACK PAGE) PLUGGING DATE Well Name/No. Location 1/4 1/4 1/4 Ft FSL of 1/4 Sec Total Depth 1/4 Sec Twp Ft FWL of 1/4 Sec Base of Treatable Water Rge County Well Classification OPERATOR Name Locate Well on Grid OTC/OCC No. Address Phone City State PIPE RECORD Size Zip Code Run (ft) Email Addr. Pulled (ft) Conductor Surface PERFORATION DEPTHS Set 1 - From To Set 2- From To Set 3- From To Set 3- From I.C. I.C. P.C. Lnr. Plug Type of Plug Hole Size or Pipe Size Depth No. Sacks Cement Slurry Volume To Calculated TOC Measured Top of Plug If Tagged 1 2 3 4 5 REMARKS Reason for Plugging CEMENTER CERTIFICATION I certify that the cement plugs were placed in this well as shown on this report, per OCC instructions. The cementing was performed by me or under my direct supervision. I certify that all cementing data is true, correct and complete. Signature Date Name and Title Typed or Printed Company Name Permit No. Address Phone City State Zip OPERATOR CERTIFICATION I declare under applicable Corporation Commission rule, that I am authorized to make this certification, that I have knowledge of the well data and information presented herein, and that data and facts presented are ture, correct, and complete to the best of my knowledge. This covers all well data and information presented herein. Signature Date Name and Title Typed or Printed CORPORATION COMMISSION USE ONLY By signing this form, the District Manager has approved the contents thereof as to form only. Said District Manager does not warrant the facts provided by the operator are true or that the operator has properly plugged the described well. Signature of District Manager Field Inspector Form 1003/1003C Rev. 2017 INSTRUCTIONS: Form 1003/1003C 1. Form must be completed in its entirety and mailed to the appropriate District Office (see below) within 30 days after plugging is completed. 2. Send original only. 3. Type or use BLACK ink only. This form is for record and must be legible. 4. API No. must be on form. To get an API No. use the OCC online Data Mining application or call the OCC Well Records Department at (405) 521-2275. 5. In specifying the type of plug use the following notations: ( if other abbreviations are used, please define ) CIBP - cast iron bridge plug CEM - cement plug CIBP + CEM - cast iron bridge plug and cement PKR - packer 6. Cement plugs shall be placed in the well bore as required by the Rules of the Commission plus any additional plugs as may be specified by the District Manager or his representative, where unusual local conditions exist. (OAC 165:10-11-6) 7. The minimum amount of cement normally used in each plug in the open hole shall be a slurry volume equal to the amount necessary to fill the calculated volume of 100 feet of the hole in which the plug is placed. 8. A minimum 30 foot cement plug is required to be placed in the top of the well. (OAC 165:10-11-6) DISTRICT I (Bristow) District Office Adair Muskogee Rogers Cherokee Noble Tulsa Craig Nowata Wagoner 115 W. 6th Avenue Bristow, OK 74010-2801 (918) 367-3396 Counties Served: Creek Delaware Kay Lincoln Mayes Okfuskee Okmulgee Ottawa Pawnee Payne Washington DISTRICT II (Kingfisher) District Office 101 S. 6th Street Kingfisher, OK 73750-3209 (405) 375-5570 Counties Served: Alfalfa Beaver Blaine Canadian Cimarron Custer Dewey Ellis Garfield Grant Harper Kingfisher Logan Major Oklahoma Roger Mills Texas Woods Woodward DISTRICT III (Duncan) District Office 1111 W. Willow Avenue Ste. 100 Duncan, OK 73533-4759 (580) 255-0103 Counties Served: Beckham Caddo Carter Cleveland Comanche Cotton Garvin Grady Greer Harmon Jackson Jefferson Kiowa Love McClain Murray Stephens Tillman Washita DISTRICT IV (Ada) District Office Atoka Leflore Seminole Bryan Marshall Sequoyah Choctaw McCurtain 1400 Hoppe Blvd. Suite "D" Ada, OK 74820-2312 (580) 332-3441 Counties Served: Coal Haskell Hughes Johnston Latimer McIntosh Pittsburg Pontotoc Pottawatomie Pushmataha FOR COMMISSION USE ONLY Approved Rejected Approved Rejected 1. API No. invalid. 10. Record of pipe pulled incomplete. 2. Legal Description invalid for County. 11. Well location does not match plat. 3. Operator No. missing/invalid. 12. Treatable water depth missing. 4. Well location missing/invalid. 13. Perforation depths missing. 5. Well name missing. 14. Information on plug - operator. 6. Well No. missing. 15. Plugging description missing. 7. Plugging date invalid. 16. Plugging contractors name missing. 8. Well type missing/invalid. 17. Information on plug-cementing company. 9. Total depth missing/invalid. 18. Other: http://www.occeweb.com/og/ogdistricts.htm
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