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: (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, for an operator whose statewide plugging liability is less than $25, 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: , 165: , 165: and 165: ] Question concerning this Form: Contact the Surety Department (405)

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