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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