1003 1003c Form

User Manual: 1003C

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Form 1003/1003C
Rev. 2017
API NO.
OTC PROD. UNIT NO.
PLUGGING DATE
Well Name/No.
Location
1/4 1/4 1/4 1/4 Sec Twp
Rge
Ft FSL of 1/4 Sec
Ft FWL of 1/4 Sec County
Total Base of Well
Depth Treatable Water
Classification
OPERATOR Locate Well on Grid
Name OTC/OCC No.
Address
Phone
City State Zip Email
Code Addr.
PIPE RECORD
Conductor
Surface Set 1 -
From
To
I.C.
Set 2-
From
To
I.C.
P.C.
Set 3-
From
To
Lnr.
Set 3-
From
To
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
TOC
Measured Top of Plug
If Tagged
PERFORATION DEPTHS
Pipe Size
Depth
No. Sacks
Cement
Slurry
Volume
Type of Plug
Hole Size or
Calculated
Size
Run (ft)
Pulled (ft)
TYPE OR USE BLACK INK
PLUGGING RECORD
OAC 165:10-11-7
(PLEASE SEE INSTRUCTIONS ON BACK PAGE)
OKLAHOMA CORPORATION COMMISSION
TO SEND THIS FORM TO THE OCC, PLEASE
USE THE APPROPRIATE DISTRICT OFFICE
ADDRESS (ON THE BACK OF THIS FORM)
Form 1003/1003C
INSTRUCTIONS: Form 1003/1003C Rev. 2017
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 )
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)
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:
FOR COMMISSION USE ONLY
Washington
Kingfisher
Seminole
Sequoyah
Johnston
Latimer
Leflore
Marshall
McCurtain
McIntosh
Pittsburg
Pontotoc
Pottawatomie
Pushmataha
DISTRICT IV (Ada) District Office 1400 Hoppe Blvd. Suite "D" Ada, OK 74820-2312 (580) 332-3441
Counties Served:
Atoka
Bryan
Choctaw
Coal
Haskell
Hughes
Stephens
Tillman
Washita
Garvin
Grady
Greer
Harmon
Jackson
Jefferson
Kiowa
Love
McClain
Murray
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
Texas
Woods
Woodward
Ellis
Garfield
Grant
Harper
Logan
Major
Oklahoma
Roger Mills
Alfalfa
Beaver
Blaine
Canadian
Cimarron
Dewey
Payne
Wagoner
Counties Served:
DISTRICT II (Kingfisher) District Office 101 S. 6th Street Kingfisher, OK 73750-3209 (405) 375-5570
Counties Served:
Rogers
Noble
Nowata
Okfuskee
Okmulgee
Ottawa
Tulsa
Delaware
Kay
Lincoln
Mayes
Muskogee
Pawnee
CIBP - cast iron bridge plug CEM - cement plug CIBP + CEM - cast iron bridge plug and cement PKR - packerCIBP - cast iron bridge plug CEM - cement plug CIBP + CEM - cast iron bridge plug and cement PKR - packer
Approved Rejected
Approved Rejected
DISTRICT I (Bristow) District Office 115 W. 6th Avenue Bristow, OK 74010-2801 (918) 367-3396
Adair
Cherokee
Custer
Craig
Creek
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