1. FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS

2. 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

3. FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS OTC/OCC NUMBER: This is the operators identification number. New operators please leave this field blank.

4. FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS NAME OF WELL PLUGGER

5. FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS WELL PLUGGER’S PERMIT NUMBER

6. FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS NAME OF THE WELL OPERATOR

7. FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS ESTIMATED COST TO PLUG WELL

8. FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS WELL OPERATORS AND WELL PLUGGERS TAKE NOTE

9. FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS WELL NAME AND NUMBER

10. FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS API NUMBER IF IT IS AN EXISTING WELL, NEW WELL TO BE DRILL LEAVE BLANK

11. FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS LEGAL LOCATION OF THE WELL (SECTION, TOWNSHIP, RANGE WITH QUARTER CALLS)

12. FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS COUNTY IN WHICH THE WELL RESIDES

13. FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS TOTAL DEPTH OF THE WELL

14. FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS WELL CLASSIFICATION

15. FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS SPECIAL INSTRUCTIONS FOR BOTH THE OPERATOR AND THE WELL PLUGGER

16. FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS SIGNATURE BLOCK FOR THE WELL PLUGGER

17. FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS NOTARY SEAL AND SIGNATURE

18. FORM 1006D – AFFIDAVIT OF WELL PLUGGING COSTS OCC USE ONLY – DO NOT WRITE IN THIS SPACE