1. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING

2. This presentation will assist you in the completion of the Form 1003A. The notice of temporary exemption from plugging. Date of Last Revision: 2011 Rule Requirement: OAC 165:10-11-9 Explanation of Form: Form 1003A shall be filed with the appropriate Conservation Division District Office. [Reference 165:10-11-3 and 165:10- 11-9] Question concerning this Form: Contact your Local District Office

3. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING READ INSTRUCTIONS

4. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING CHECK BOX ON WHETHER THIS IS AN ORIGINAL, AN AMENDMENT OR A RENEWAL APPLICATION AND WHAT THE ORIGINAL APPLICATION DATE IS

5. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING OPERATOR’S NAME, ADDRESS AND OPERATOR’S NUMBER

6. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING LEASE/WELL NAME AND NUMBER

7. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING API NUMBER

8. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING OTC (OKLAHOMA TAX COMMISSION) LEASE NUMBER

9. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING SPOT LOCATION AND FOOTAGE FROM THE SOUTH AND THE WEST LINES OF THE ¼ SECTION

10. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING LEGAL LOCATION

11. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING COUNTY WHERE THE WELL IS LOCATED

12. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING DATE THE WELL WAS COMPLETED

13. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING DATE OF LAST PRODUCTION/USED AS UTILITY WELL

14. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING IS WELL LOCATED ON A VALID OR PRODUCING LEASE OR UNIT

15. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING DEPTH TO THE BASE OF TREATABLE WATER

16. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING SURFACE CASING SET AT WHAT DEPTH

17. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING LATEST TEST DATA

18. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING PRODUCING FORMATION(S) ALONG WITH PERFORATIONS WITH ANY SPACING SIZE/ORDER NUMBER(S)

19. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING DATES OF EITHER TEMPORARY ABANDONMENT, THE ORIGINAL DATE OF ABANDONED AND HOW LONG IS THE REQUESTED EXEMPTION REQUESTED (Up to 5 years)

20. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING REASON FOR EXEMPTION FROM PLUGGING

21. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING METHOD OF TEMPORARY PLUGGING FOR THE PROTECTION OF THE TREATABLE WATER SANDS

22. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING DATE OF FLUID LEVEL SURVEY

23. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING FIELD INSPECTOR THAT WITNESSED THE TEMPORARY ABANDONMENT

24. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING SIGNATURE BLOCK

25. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING LOCAL DISTRICT OFFICES MAILING ADDRESSES AND PHONE NUMBERS

26. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING BORE HOLE SCHEMATIC

27. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING IMPORTANT INFORMATION CONCERNING TEMPORARY ABANDONMENT

28. FORM 1003A – NOTICE OF TEMPORARY EXEMPTION FROM PLUGGING OCC USE ONLY – Do not write in this box