Gas Plant Report - Form 12

Gas Plant Report - Form 12 Department of Mineral Resources Oil and Gas Division 600 East Boulevard Dept 474 Bizmark, N.D 58505 to 0614 S.F.N 18670 (08 to 2013)

Checkbox option: Amended

Please Read Instructions Before Filling Out Form.

Please Submit the Original.

Field: Reset View Print

Field: For Month/Year

Field: Gas Plant Name

Is Condensate Collected at Compressor Stations?

Checkbox option: No

Checkbox option: Yes - Number of Compressor Stations:

Field: Gas Plant Operator

Field: Telephone Number

Field: Address

Field: City

Field: State

Field: Zip Code

Intake M.C.F

Field: Total Gas From North Dakota Oil Wells (List Wells on Form 12a)

Field: Total Gas From North Dakota Gas Wells (List Wells on Form 12a)

Field: Total Gas From Other Sources (List Sources on Form 12a)

Field: Monthly Total

Disposition M.C.F

Field: Plant Use

Field: Returned to Lease

Field: Vented and Flared

Field: Extraction Loss

Field: Monthly Total

Plant Production Volume

Field: Condensate (Gallons)

Field: Propane (Gallons)

Field: Butane (Gallons)

Field: Gasoline (Gallons)

Field: Sulfur (Long Tons)

Field: Ethane (Gallons)

Field: Y-Grade Mix (Gallons)

Field: Other - List:

Details of Sales or Other Disposition M.C.F

Field: Name of Purchaser

Field: Address

Field: Used For

Field: Monthly Total

Field: Comments

I hereby swear or affirm that the information provided is true, complete and correct as determined from all available records.

Field: Date

Field: Signature

Field: Printed Name

Field: Title

Above Signature Witnessed By

Field: Witness Signature

Field: Witness Printed Name

Field: Witness Title

Gas Plant Report - Form 12 S.F.N 18670

1. This report is required as a regular monthly report, regardless of the status of operations.

2. Please refer to Section 43-02-03-83 of the North Dakota Administrative Code regarding Gas Plant Reports.

3. All volumes shall be corrected to 14.73 P.S.I.A and 60 degrees F.

4. Include in "Total Gas From Other Sources", gas produced from wells outside North Dakota.

5. Long ton is defined as 1.12 tons.

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

7. 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.