Fracture Stimulation

FRACTURE STIMULATION

COMPLETION REPORT

FORM OCSG-F04

This form is to assist title holders to submit a Fracture Stimulation Completion Report.

Petroleum (Onshore) Act 1991

Petroleum (Onshore) Regulation 2007

NSW Code of Practice for Coal Seam Gas – Fracture Stimulation Activities (Sept 2012)

PRIVACY STATEMENT

NSW Department of Industry, Skills and Regional Development may make the information on this form and any attachments available for inspection by members of the public, including by publication on the NSW Department of Industry website or by displaying the information at any of its offices. If you consider any part of your application or information to be confidential, please provide that part in a separate addendum clearly marked "Confidential".

NSW Department of Industry may also provide the information to other government agencies for the purposes of its assessment. You may access or correct your information by contacting NSW Department of Industry.

ACCESSIBILITY

NSW Department of Industry may publish the fracture stimulation completion report on its website (Section 14.2 Code of Practice for Coal Seam Gas – Fracture stimulation activities – September 2012).

NSW Department of Industry, Skills and Regional Development

OCSG Fracture Stimulation Completion Report Form OCSG-F04. TRIM: V13/3471

Version 2 –July 2015.

Download copies of this form from www.resourcesandenergy.nsw.gov.au

Fracture stimulation completion report

A fracture stimulation completion report is due within 30 days of the cessation of the fracture stimulation activity.

This form is provided to assist title holders in NSW who are required to submit a fracture stimulation completion report in conformity with the Code of Practice For Coal Seam Gas – Fracture Stimulation Activities (September 2012)..

LODGEMENT INSTRUCTIONS

The completed and signed fracture stimulation completion report must be addressed to “NSW Department of Industry”, marked “Attention: Petroleum Safety Unit”.

Forms can be submitted via one of the following options:

Mail: NSW Department of Industry

PO Box 344,

Hunter Region Mail Centre, NSW 2310

Email: Completed and saved PDF applications can be submitted to
In Person: NSW Department of Industry

Office of Coal Seam Gas,

516 High Street, Maitland NSW 2320

Fax: (02) 4931 6793

Information in support of the application or any additional information which does not fit within the form should be attached and forwarded with the original application form.

Keep a copy for your records.

For further information on lodgement please call 02 4931 6401 or

Email:

FRACTURE STIMULATION COMPLETION REPORT - DETAILS

Part A - Title Details
Title Number:
Part B – Details of Title holder
Principal Title holder Name:
ACN: (if applicable)
ABN: (if applicable)
Primary Contact Person:
Position:
Postal Address:
State: / Postcode:
Contact Details: / Phone: / Mobile:
Fax: / Email:
Part C – Details of Operator (if different)
Name of the Operator:
Primary Contact Person:
Operator’s ACN (if a corporation):
Operator’s ABN (if a corporation):
Business Address of the Operator:
State: / Postcode:
Postal Address (if different from above):
State: / Postcode:
Contact Details: / Phone: / Mobile:
Fax: / Email:
Part D – Details of Fracture Stimulation Contractor
Contractor Name:
ACN: (if applicable)
ABN: (if applicable)
Primary Contact Person:
Postal Address:
State: / Postcode:
Contact Details: / Phone: / Mobile:
Fax: / Email:
Part E – Well Details
Well Set Name:
Well Name:
Coordinates of Wellhead: / Eastings: / Northings:
Latitude: / Longitude:
Zone:
Datum:
Fracturing Commencement Date: (dd/mm/yy)
Fracturing Completion Date: (dd/mm/yy)
Well Name:
Coordinates of Wellhead: / Eastings: / Northings:
Latitude: / Longitude:
Zone:
Datum:
Fracturing Commencement Date: (dd/mm/yy)
Fracturing Completion Date: (dd/mm/yy)
Note: Attach separate sheets for additional wells
Part F - Fracture Stimulation Completion Report
Note: A title holder must submit a completed Fracture Stimulation Completion Report to the Department, which contains the information specified in Section 14.2 Code of Practice for Coal Seam Gas – Fracture Stimulation Activities for the well operation within 30 days of cessation of the fracture stimulation activity.
The Fracture Stimulation Completion Report should also contain an assessment of the fracture stimulation, as per Section 14.2(b)(v) Code of Practice for Coal Seam Gas – Fracture Stimulation Activities.
Note: One Fracture Stimulation Completion Report can be submitted for multiple wells.
Minimum Contents of Fracture Stimulation Completion Report
CHECKLIST / Included?
Y
 / N

Well Name(s):
Coordinates of Wellhead(s): / Eastings/Northings:
Latitude/Longitude:
Zone/Datum:
Fracturing commencement date:
Fracturing completion date:
Details of each interval fractured:
Summary of operations (including volume and type of chemicals used in each stage):
Assessment of Fracture Stimulation /  / 
Fracture Stimulation Management Plan (FSMP) / Reference:
Date approved:
Casing and bottom hole pressure with time
Bottom hole calculated proppant concentration
Rate that fracturing fluid was pumped over time and the total volume pumped at each stage
Composition of the fracturing fluid and any other chemicals introduced into the well (quantity of each component; concentration of each component; name of chemical compounds contained in fluid)
Concentration of proppant over time
Maximum surface pressure at each stage
Estimated fracture gradient for the target interval
Details of equipment and diagnostic techniques used
Hazards for Future Coal Mining /  / 
If fracturing has been undertaken on a coal seam – any other details to assist future assessment of the impact on the seam, and any increased risk to safe and efficient mining of coal
Environmental Harm /  / 
If a known event related to the fracturing activities has caused material environmental harm, details of each step taken to mitigate the harm.
Hydraulic Fluid Fracturing Statement /  / 
A hydraulic fluid fracturing statement
Part G - Authority
The name and signature of the title holder, or the person authorised to sign on behalf of the title holder, is required as follows:
If the title holder is a natural person:
I, Click here to enter text – Insert name
hereby declare that to the best of my knowledge, I am the title holder and that the information supplied in support of this Fracture Stimulation Completion Report is true and correct.
I make this declaration knowing, under the Crimes Act 1900 (Section 307B), that knowingly giving false or misleading information is a serious offence; and under the Petroleum (Onshore) Act 1991 (section 135) that any person who inserts false particulars in any records directed or required by or under this Act to be furnished or made or supplies any false information when directed or required under this Act to supply any information is guilty of an offence.
[Click within signature box to insert image]

NSW Department of Industry, Skills and Regional Development

OCSG Fracture Stimulation Completion Report Form OCSG-F04. TRIM: V13/3471

Version 2 –July 2015.

Download copies of this form from www.resourcesandenergy.nsw.gov.au

Signature:

NSW Department of Industry, Skills and Regional Development

OCSG Fracture Stimulation Completion Report Form OCSG-F04. TRIM: V13/3471

Version 2 –July 2015.

Download copies of this form from www.resourcesandenergy.nsw.gov.au

Position: / Date:
(dd/mm/yy)
If the title holder is a corporation:
I, Click here to enter text – Insert name
hereby declare that I am authorised to sign this declaration on behalf of
Company name: / ACN:
I further declare that to the best of my knowledge this company is the title holder and that all the information supplied in support of this Fracture Stimulation Completion Report is true and correct.
I make this declaration knowing, under the Crimes Act 1900 (Section 307B), that knowingly giving false or misleading information is a serious offence; and under the Petroleum (Onshore) Act 1991 (section 135) that any person who inserts false particulars in any records directed or required by or under this Act to be furnished or made or supplies any false information when directed or required under this Act to supply any information is guilty of an offence.
[Click within signature box to insert image]