MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY - OIL, GAS, AND MINERALS DIVISION

RECORD OF WELL DRILLING OR DEEPENING

Required by authority of Part 615 Supervisor of Wells or Part 625 Mineral Wells, of Act 451 PA 1994, as / Permit number/Deepening number
amended. Non-submission and/or falsification of this information may result in fines and/or imprisonment.
API number
(Submit within 60 days of drilling completion.)
Well name and number
Part 615 Oil/Gas Well Part 625 Mineral Well!
Name and address of permittee / Surface location
l1/4 of l1/4 of l 1/4 Section T R
Township / County
Footages North/SouthEast/West
Name and address of drilling contractor / lft. fromlline and ft. from line of sec.
Directionally drilled (check one) / Previous permit numbers
Yes No
Subsurface location (if directionally drilled)
1/4 of 1/4 of l1/4 Section T R
Date drilling began / Date drilling completed / TownshipCounty
Total depth of well / Formation at total depth / Footages North/SouthEast/West
Driller lLog l / lft. fromlline and ft. from line of sec.
Elevations / Feet drilled - cable tools / Feet drilled - rotary tools
K.B. ft. R.F. l ft. R.T. l ft. Grd ft / from lto l / from lto
Casing, Casing Liners and Cementing, Operating Strings / Water Fill Up (F.U.) or Lost Circulation (L.C.) (X)
Size / Where set / Cement / T.O.C. / Ft. pulled / Formation / F.U. / L.C. / Depth / Amount
l / l / l / l / l / l / l / l
l / l / l / l / l / l / l / l
l / l / l / l / l / l / l / l
l / l / l / l / l / l / l / l
l / l / l / l / l / l / l / l
Gross Pay Intervals / All Other Oil and Gas Shows Observed or Logged
Formation / Oil or Gas / From / To / Where Observed (X)
l / l / l / l / Formation / Oil or / Depth / Sam- / Mud / Gas / Fill
l / l / l / l / Gas / ples / Odor / Pits / Line / Log / Up
l / l / l / l / l / l / l
l / l / l / l / l / l / l
l / l / l / l / l / l / l
Depth Correction / Deviation Survey / Plugged Back
Depth / Correction / Run at / Degrees / Yes / No / Depth
l / l / l / l / l
l / l / l / l / l
l / l / l / l / l
l / l / l / l / l
Geophysical / Mechanical Logs (list each type run)
Brand / Log types / Logged intervals
l / l / l
l / l / l
l / l / l
l / l / l
Notice: Report complete sample and formation record, coring record, and drill stem test information on reverse side.
Certification “I state that I am authorized by said owner. This report was prepared under my supervision and direction. The facts stated herein are true, accurate and complete to the best of my knowledge.”
Date / Name and title (print) / Signature

Mail originalwithin 60 days after drilling completion to: Oil, Gas, and Minerals Division, Michigan Department of Environmental Quality,

P.O. Box 30256, Lansing, MI 48909-7756

Or submit via email to

EQP 7200-5 (rev. 2/2017)

FORMATION RECORD / API number / Permit number/Deepening number
Attach additional sheets if necessary
Elevation used / Geologist name / Tops taken from
lDriller’s logl Sample logl Electric log!
Formation / Formation
From / To / (type, color, hardness) / From / To / (type, color, hardness)
Note:!if well directionally drilled, add true vertical depth formation tops where appropriate / !
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! / If well was cored, attach core description!
! / DRILL STEM TEST DATA!
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! / OIL, GAS, AND MINERALSDIVISIONUSE ONLY!
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EQP 7200-5 (rev. 2/2017) page 2