FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS

FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS This presentation will assist you in the completion of the Form 1006D. The affidavit of well plugging costs.

Date of Last Revision: 2003

Rule Requirement: OAC 165:10-1-10(3)

Explanation of Form: An operator may submit an affidavit on Form 1006D to the Conservation Division concerning the operator’s statewide plugging liability. The Commission may approve Category B surety in an amount less than $25,000.00 for an operator whose statewide plugging liability is less than $25,000.00. The Form 1006D must be properly executed by a duly licensed pipe pulling and well plugging company and such Form must be acceptable to the Conservation Division. [Reference 165:10-1-10, 165:10-1-12, 165:10-1-13 and 165:10-1-14]

Question concerning this Form: Contact the Surety Department (405) 521-2246

FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS

OTC/OCC NUMBER: This is the operators identification number. New operators please leave this field blank.

FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS

NAME OF WELL PLUGGER

FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS

WELL PLUGGER’S PERMIT NUMBER

FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS

NAME OF THE WELL OPERATOR

FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS

ESTIMATED COST TO PLUG WELL

FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS

WELL OPERATORS AND WELL PLUGGERS TAKE NOTE

FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS

WELL NAME AND NUMBER

FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS

API NUMBER IF IT IS AN EXISTING WELL, NEW WELL TO BE DRILL LEAVE BLANK

FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS

LEGAL LOCATION OF THE WELL (SECTION, TOWNSHIP, RANGE WITH QUARTER CALLS)

FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS

COUNTY IN WHICH THE WELL RESIDES

FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS

TOTAL DEPTH OF THE WELL

FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS

WELL CLASSIFICATION

FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS

SPECIAL INSTRUCTIONS FOR BOTH THE OPERATOR AND THE WELL PLUGGER

FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS

SIGNATURE BLOCK FOR THE WELL PLUGGER

FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS

NOTARY SEAL AND SIGNATURE

FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS

OCC USE ONLY – DO NOT WRITE IN THIS SPACE