form21

One-Point Back-Pressure Test Report - Form 21 Department of Mineral Resources Oil and Gas Division 600 East Boulevard Dept 474 Bismark, N.D 58505 to 0614 S.F.N 18713 (02 to 2008)

Field: Well File No.

Please Read Instructions Before Filling Out Form.

Please Submit the Original.

Field: Type of Test

Checkbox option: Initial

Checkbox option: Annual

Checkbox option: Special

Field: Date of Test

Field: Operator

Field: Telephone Number

Field: Address

Field: City

Field: State

Field: Zip Code

Field: Well Name and Number

Field: Qtr-Qtr

Field: Section

Field: Township

Field: Range

Field: County

Field: Field

Field: Pool

Field: Total Depth (Feet)

Field: Perforations (Feet)

Field: Type Completion (Describe)

Field: Packer Depth (Feet)

Field: From

Field: To

Field: Producing Through

Field: Reservoir Temperature (°F)

Field: Mean Annual Temperature (°F)

Field: Barometric Pressure, P B (P.S.I.A)

Field: @

Field: Feet

Field: L (Feet)

Field: H (Feet)

Field: G s

Field: %C-O 2

Field: %N 2

Field: %H 2S

Field: Prover I.D

Field: Meter Run I.D

Field: In

Field: In

Field: Taps Type

Tubing Data

Casing Data

Flow Data

Field: No.

Field: Pressure (P.S.I.G)

Field: Temperature (°F)

Field: Pressure (P.S.I.G)

Field: Temperature (°F)

Field: Prover Line Size (In)

Field: Choke Orifice Size (In)

Field: Pressure (P.S.I.G)

Field: Meter Differential Pressure h w (In)

Field: Temperature (°F)

Field: Duration of Flow (Hour)

Field: S1

Field: No.

Field: Coefficient, F s (24-Hour)

Field: Square Root of h w P w

Field: Pressure, P w (P.S.I.A)

Field: Flow Temperature Factor, F t

Field: Gravity Factor, F g

Field: Super Compressibility Factor, F sc

Field: Rate of Flow, Q (M.C.F.D)

Field: 1.

Field: No.

Field: P r

Field: Abs. Temperature, T (°R)

Field: T r

Field: z

Field: Gas Liquid Hydrocarbon Ratio

Field: Mcf/Bbl

Field: A.P.I Gravity of Liquid Hydrocarbons

Field: deg.

Field: Separator Gas

Field: Flowing Fluid

Field: Specific Gravity

Field: Specific Gravity

Field: Critical Pressure

Field: P.S.I.A

Field: Critical Pressure

Field: P.S.I.A

Field: Critical Temp.

Field: Critical Temp.

Field: R Critical Temp.

Field: *R

Field: P r (P.S.I.A)

Field: P r squared/1000

Field: P r (P.S.I.A)

Field: P r squared/1000

Field: No.

Field: P 1 (P.S.I.A)

Field: P 1 squared/1000

Field: P 2 squared - P 1 squared (1000)

Field: P w (P.S.I.A)

Field: P w squared/1000

Field: P w squared - P 2 squared (1000)

Field: P s (P.S.I.A)

Field: P s squared/1000

Field: P w squared - P s squared (1000)

Field: 1.

P 1 squared log P 2 squared

P r squared, P w squared P 2 squared, P w squared

P 1 squared n log P 2 squared

P 2 squared - P w squared P 2 squared, P w squared

A.O.F = Q P s squared

P 2 squared - P w squared n

A.O.F M.C.F.D n In Source c

Field: Signature

Field: Printed Name

Field: Title

Field: Date