Notification of Well Spud Form

(February 2015)

UNITED STATES Lease Number

DEPARTMENT OF THE INTERIOR

BUREAU OF INDIAN AFFAIRS

OSAGE AGENCY

NOTIFICATION OF WELL SPUD Unit Name/Number

New Well Spud 24 Hour Prior Notice

API Well Number

Re-Entry

Deepening of Existing Well

Field

Other _________________

Location of Well

Qtr: __________ Section: __________ Twn: _______ Rng: ________ County: ___________________________ State: _________

Operator Call Taken By

Name of Caller Phone

Date Notified Time Notified

Date of SPUD Date Plan to Spud

Time of SPUD Time Plan to Spud

Contractor Name/ Drilling Rig Number

Date and Time Plan to Run Casing

(Instruct Operator to Notify the Office 12 Hours Prior to Running Casing)

L ease Expiration? Yes No

Expiration Date

Proposed Total Depth of Well BOPE RATING: 2M 3M 5M 10M

REMARKS

Paperwork Reduction Act (PRA) Statement: This information is collected to meet reporting requirements and is subject to the PRA. An agency may not request nor sponsor, and a person need not answer a request for information that does not display a valid OMB control no. A response to this request is required to obtain a benefit. The public reporting burden for this form is estimated to average 8 hours per response, including the time for reviewing the instructions, gathering and maintaining data, and completing and reviewing the form. Send comments on the burden estimate or any other aspect of this form to Information Collection Clearance Officer–Indian Affairs, 1849 C Street, NW, MS-3642, Washington, DC 20240.