WPC 2 ZB0R5WQB1_16-21x6X@7X@Њ TT ӫx6X@7X@<6X9`(CourierXd6X@@<6X9`(Courierx6X@7X@<6X9`(CourierXXx6X@X@<( 9Z &Courier RegularXx6X@7X@<6X9`(CourierXC2PP,rAZ"Arial RegularXx6X@X@<( 9Z &Courier RegularXd6X@@<( 9Z &Courier RegularXx6X@X@<( 9Z &Courier RegularX23|6 ,  T  REGION 5 UIC CLASS II TECHNICAL REVIEW SHEET ă`(#?#d6X@@#(revised 9/18/96)#x6X@7X@#у I.HEADER INFORMATION Permit County_______________________________Application #_______________________ Twnshp, Rnge_________________________Operator____________________________ ____1/4 of____1/4 of____1/4 Sect_____Well________________________________ ____Ft. from N/S line Quarter SectionState Permit #______________________ ____Ft. from E/W line Quarter SectionPermit Writer_______________________ Latitude ____$____'___.___" North Longitude ____$____'___.___" West II.WELL STATUS Existing Date drilled ___/___/___ Converted#Xx6X@X@#` ` ` Date converted ___/___/___ #x6X@7X@# h #C2PP#Circle one#Xx6X@X@# Proposed New  h Proposed Conversion    ` ` ` hhh  III.AREA OF REVIEW AOR map showing well(s) attached to application? _______ How many wells in the AOR penetrate the injection zone? ______ Of these wells, how many are: T.A.'ed. _____hhhConstruction Adequate? _____ P.A.'ed. _____hhhConstruction Adequate? _____ Producers _____Construction Adequate? _____ Injectors _____Construction Adequate? _____ List submitted naming owner(s) of record within the AOR? ______ Map showing landowners within the AOR? ______ IV.UNDERGROUND SOURCES OF DRINKING WATER Formation name of lowest USDW: _________________________________________ Depth to USDW base: ___________ Methods of USDW determination: Atlas ____________ Well control ____________ Other ____________  V. GEOLOGIC DATA OF CONFINING AND INJECTION ZONE ` ` ` Injection Zone Confining Zone  Fm. Name(s) _________________________ __________________________  Lithology _________________________ __________________________ Depth to top_________________________ __________________________ Thickness _________________________ __________________________  What is the separation between the base of the lowest USDW and the top of the injection zone? _________________ What method was used to determine maximum injection pressure? _______ Field Rules (see Federal Register Notices 61084, 61910, 65711) _______ Fracture Data: Use the ISIP pressure (Attach fracture job charts etc.) _______ Fracture gradient equation: ` ` ` [FG (.433(Sg +.05))] x depth 14.7 = _____  (Sg = ____________) from chemical analysis ` ` ` (Depth = ___________ft.) (FG = ______________psi/ft) _______ Other (explain) __________________________________________ VI.OPERATING DATA Maximum permitted injection pressure: ___________________ Maximum permitted injection rate (BPD) (if applicable): _______________ Specific gravity from chemical analysis:_______ +.05 = _______ ) P+P+ Composition of the annulus fluid: ______________________________________   VII.WELL CONSTRUCTION Total Depth ___________ft.Plugged Back Total Depth ___________ft. Formation at T.D. ______________________ Type of Completion:  Perforations depths ___________ to ___________ft.  Open hole depths ___________ to ___________ft. Packer depth ___________ft. Packer to be set within or below the immediate confining system?______ Packer to be set within a cemented interval?______  Cement interval adjacent to casing strings: (use 20% excess)  TTT.X9  TTT.X9 .P  P  .#d6X@@#Hole8+TubularsCemented Interval.P  P  .Size (in)Size (in)Weight (lb/ft)Depths (ft)Depths (ft).P P .TopBottomTopBottom.P P .Conductor Pipe.P P .Surface Casing.P P .Intermediate Casing.P P .Long String Casing.P        P        .Liner#Xx6X@X@# VIII.MECHANICAL INTEGRITY TESTING Part I Mechanical Integrity: Type of MIT to be conducted upon well completion: ________________________________________________________________________ Part II Mechanical Integrity: ______ Cement ` ` ` Proof of cement is/to be demonstrated by submitting: ` ` ` ______ Signed State completion report ` ` ` ______ Cementing tickets ` ` ` ______ Cement Bond Log ______ Temperature / Noise survey / Oxygen Activation Log Other logs run: _______________________________________________________________ IX.PLUGGING AND ABANDONMENT ______ All uncemented casing ripped. ______ Plug of at least 250 feet set immediately above the top of the injection zone. ______ 50 feet of cement immediately above cast iron bridge plug. 250 feet is required above cement retainer if situated adjacent to the injection zone. ______ Cement plug set at least 50 feet above and 50 feet below any rip point. ______ If surface casing is not cemented to surface , cement plug set at least 50 feet below the lowest USDW to surface. ______ If surface casing is cemented to surface and extends below the lowermost USDW, a cement plug from at least 50 feet above the USDW base to 50 feet below the shoe is required and a cement plug from at least 50 feet depth to the surface is required. ______ If surface casing is cemented to surface and the lowermost USDW is below the surface casing setting depth, a cement plug from at least 50 feet below the USDW base to 50 feet above the casing shoe is required and a cement plug from at least 50 feet depth to the surface is required. ______ If the lowermmost USDW is less than 500 feet deep , a continuous cement plug is set from at least 50 feet below the base of the lowermost USDW to the surface. Explain any variation from the above: __________________________________ ________________________________________________________________________ X.COMPLIANCE WITH OTHER FEDERAL ACTS  Wild and Scenic Rivers Act : Any designated Wild and Scenic Rivers within the quarter mile AOR? ______ If so, give name(s) _________________________________________________  Endangered Species Act : Has the Permit Writer contacted U.S. Fish and Wildlife Service for a list of Endangered or Threatened Species? ______ Written response from U.S. FWS? ___________ Any listed species present? __________ If yes, list:________________  National Historic Preservation Act : State Historic Preservation Office contacted? ________ Historic Resources present? ____________________________________________    Coastal Zone Management Act : Is the well located in a Michigan county which borders the Great Lakes?______ If "yes", then has the permit writer contacted the Michigan Coastal Management Program (CMP) in writing?_________ If the Michigan CMP has not been contacted in writing and the well is located in a Michigan county which borders the Great Lakes, then ensure that the Michigan CMP office is included in the public notice list: ` ` ` Ms. Cathy Cunningham, Land and Water Management Analyst ` ` ` Michigan Department of Natural Resources ` ` ` Division of Land and Water Management ` ` ` Coastal Management Program, P.O. Box 30458 ` ` ` Lansing, Michigan 48909  Fish and Wildlife Coordination Act : Does permit application call for diverting, impounding, deepening or controlling any surface water body in excess of 10 acres?__________ XI.FINANCIAL ASSURANCE Type __________________________________________________________________ Amount ________________________________________________________________ Provider ______________________________________________________________ Standby Trust provided ________________________________________________ If Blanket Bond coverage: ` ` ` Is Form VII10 acceptable? _______ ` ` ` Is the amount equal to 10 times the cost to plug the most expensive injection well in the field or 75% of the total cost to plug all wells? ______ ` ` ` List of all wells covered under the blanket bond provided? _______ If State Bond Coverage: ` ` ` Has a letter of intent to use this type of bond been submitted by the operator? ______  ` ` ` Has a copy of the state bond been provided? __________ XII.CONFIDENTIALITY Has any part(s) of this permit application been declared confidential by the operator? _______. If yes, then specify the confidential parts:__________________________ Permit writer signature _____________________________ Date:___/___/___