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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