Saltwater Disposal Report Continuation - Form 16a

Saltwater Disposal Report Continuation - Form 16A Department of Mineral Resources Oil and Gas Division 600 East Boulevard Dept 474 Bismarck, N.D 58505 to 0614 S.F.N 5764 (03 to 2000)

Field: Page

Field: of

Checkbox option: Amended

please read instructions before filling out Form. please submit the original.

Field: For Month/Year

Field: Well Name and Number

Field: Field

Field: U.I.C Number

Field: Operator

Field: Telephone Number

Source of Disposal Water and Method of Transportation

Field: Operator, Well Name and Number

Field: Well File Number

Field: Location (Qtr-Qtr, S-T-R)

Field: Pit (P) or Well (W)

Field: Monthly Barrels Transported

Field: Pipeline (P) or Truck (T)

Field: Monthly Total

Field: Comments

Saltwater Disposal Report Continuation - Form 16A S.F.N 5764

1. This report shall only be filed when attached to a completed Saltwater Disposal Report - Form 16 (S.F.N 5763).

2. Please refer to Section 43-02-05-12 of the North Dakota Administrative Code (N.D.A.C) regarding reporting requirements for injection wells.

3. The well name and number, field, and U.I.C number of the saltwater disposal well and the operators, well names and numbers, well file numbers and locations of the source wells shall coincide with the official records on file with the Commission.

4. All volumes shall be reported as barrels (42 gallons) and rounded to the nearest full barrel.

5. The operators of source wells that dispose of fluids in this disposal well shall be listed.

6. If the source of disposal water is not a particular well site, only the location need be listed.

7. When reporting source of disposal water and method of transportation, a "P" or "W" is sufficient to indicate pit or well water, and a "P" or "T" is sufficient to indicate transportation by pipeline or truck.

8. Monthly barrels transported shall be totaled at the end of the report.

9. If this is an amended report, the amended volumes shall be clearly indicated.

10. The original of this report shall be filed with the Department of Mineral Resources, Oil and Gas Division, 600 East Boulevard, Dept. 474, Bismarck, N.D 58505 to 0614, by the fifth day of the second succeeding month.