REQUEST FOR CHANGE OF OPERAT&R, TRANSFER OF INJECTION OR SURFACE PIT PERMIT

Transcription

1 KANSAS CORPORATION COMMISSION OIL & GAS CONSERVATION DIVISION REQUEST FOR CHANGE OF OPERAT&R, TRANSFER OF INJECTION OR SURFACE PIT PERMIT Form T-1 April 2004 Form must be Typed Form must be Signed All blanks must be Filled Check Applicable Boxes: X- Oil Lease: No. of Oil Wells 6 Effective Date of Transfer: Henry sseoh Gas Lease: No. of Gas Wells KS Dept of Revenue Lease No Gas Gathering System. Lease Name' Sargent Saltwater Disposal Well - Permit No 11E-S1aL-NE - Sec.36 Twp PR _NE Ew Spot Location feet from NI S Line feet from El W Line Legal Description of Lease:We, st Half of the N/E j Enhanced Recovery Project Permit No.: E New Operator's License No /" Contact Person Gary Bridwell CONSFRViainN DIVISIOt WICHITA, KS New Operator's Name & Address._yGar Bridwell d/b/a Phone: Black Rain Energy Oil / Gas Purchaser P Independence,Ks Date Title Entire Project: X Yes Number of Injection Wells Field Name- Vi 1 as Owner I No Side Two Must Be Completed. 1 County- Wilson Production Zone(s). Baril6sville Injection Zone(s) Bartlesville Surface Pit Permit No feet from N / S Line of Section (API No. if Drill Pit, WO or Haul) feet from E / fl W kne of Section ' Type of Pit: Emergency I Burn Settling I Haul-Off Workover Drilling Past Operator's License No i Contact Person- Henry Jesse ph Past Operator's Name & Address' Jesseph Oil Well Ser phone Reno Rd.Buffalo,Ks Date. a'? 64fr Title: Owner Signature RECEIVED KANSATCORPORATIOWCOMMISSIOP JAN Acknowledgment of Transfer: The above request for transfer of injection authorization, surface pit permit # has been noted, approved and duly recorded in the records of the Kansas Corporation Commission. This acknowledgment of transfer pertains to Kansas Corporation Commission records only and does not convey any ownership interest in the above injection well(s) or pit permit. oci() 10A cs.,rk_.,t1- ctitt is acknowleged as the is acknowleged as the new operator and y coue to inj ct fluids as authorized by new operator of the above named lease containing the surface pit Permit No.: V Recommended action4 n010,-6m- permitted by No.: P-00". 200 Date: +5- t;;- Date: Authori Signature Authorized Signature DISTRICT EPR e PRODUCTION UIC Mail to: Past Operator I 2- New Operator t2.. District I J ( I a Mail to: KCC - Conservation Division, 130 S. Market - Room 2078, Wichita, Kansas 67202

2 ,ANNED Side Two Must Be Filed For All Wells KDOR Lease No * Lease Name: Sargent *LocabonNE SW NE Sec,36 T.27 R.16 E. Well No. API No..(YR DRLD/PRE '67) Footage from Section Line (i.e. FSL = Feet from South Line) Type of Well (Oil/Gas/INJ/WSW) Well Status (PROD/TAD/Abandoned) 1 #- 1 #-2 #-3 #-4 #-5 /5:c ' /93 9/ Circle Circle OFWL U/N 0_ NL 1815 INJ. 16-'-cav5- a 04/1) a U/N 4290 CgiNL 1413 O FE FWL Oil /5-cIDS--,D-04/03, U/N 3960 NL 1485 FWL Oil o5"- ao s4 0,(_, U/N 3630 NL 1485 FWL Oil /5:?,49Sieto5 tigi, 3300 NL 1485 FWL Oil / 5---;05.,0004/04.. U/N 3300 Ey NL 1815 ED(Fm_ 0)1.1 FSLJFNL A separate sheet may be attached if necessary * When transferring a unit which consists of more than one lease please file a separate side two for each lease. If a lease covers more than one section please indicate which section each well is located.

3 KANSAS CORPORATION COMMISSION OIL & GAS CONSERVATION DIVISION REQUEST FOR CHANGE OF OPERATOR TRANSFER OF INJECTION OR SURFACE PIT PERMIT Form T-1 April 2004 Form must be Typed Form must be Signed All blanks must be Filled Check Applicable Boxes: XI Oil Lease: No. of Oil Wells 6 I Gas Lease: No. of Gas Wells Gas Gathering System' Saltwater Disposal Well - Permit No.: Spot Location feet from I N /.* S Line Effective Date of Transfer: KS Dept of Revenue Lease No Lease Name: Sargent NE _SW NE _ Sec 36 Twp 2716 R _ X.-1E I I feet from E / W Line Legal Description of Lease West Halfof the N/ E 4 xl Enhanced Recovery Project Permit No.: R 2'134Q Entire Project: XJYes No Number of Injection Wells 1 Field Name- Vilas * Side Two Must Be Completed. County. Production Zone(s). Injection Zone(s). Wilson Bart1esVille Bartlesville Surface Pit Permit No (API No. if Drill Pit, WO or Haul) feet from feet from Type of Pit: I I Emergency I Burn I Settling I Haul-Off Workover IN / IS Line of Section E/ W Line of Section DrilIi Past Operator's License No Contact Person: Di rk CCIrTIP 3 1 Past Operator's Name & Address Hea t. Can Oil, T,T4C. Phone: P.O. Rnx 9"1"1 ChAnute Ks Title: Earl Bartholomew,Owner Date Signatu New Operator's License No j Contact Person Henry JPsseph New Operator's Name & Address- J e s s (m ph Oh 1 Well _S_e r,phone: RECEIVar KANSAS CORPORATION Reno Rd. Buffalo,Ks Oil / GasPurchaser Not-Sure-Yet COMr, ':SFIC Date JAN Title: Henry Jesseph,Owner Signature: Acknowledgment of Transfer: The above request for transfer of injection authorization, surface pit permit # WICHITA, KP has been noted, approved and duly recorded in the records of the Kansas Corporation Commission. This acknowledgment of transfer pertains to Kansas Corporation Commission records only and does not convey any ownership interest in the above injection well(s) or pit permit. Jesva c1.6()es5epli 1A,)se An ctẇtegrellia'cf--e-new operator and may con nue to inject fluids as authorized by Permit No.. - Z5. 5 L( 0 Recommended action: i Au-k-Ccish, is acknowleged as the new operator of the above named lease containing the surface pit permitted by No.: Date. DISTRICT Mail to: Past Operator Au rized Signature al.2 -/ -0 E( Date: PR PRODUCTION +5- New Operator Distn Mail to: KCC Conservation Division, 130 S. Market - Room 2078, Wichita, Kansas Authorized Signature

4 SCA NNE' Side Two Must Be Filed For All Wells KDOR Lease No.: * Lease Name: S r a ia4t. gent * Location NE SW NT', SPC'.36 T.?7 S., R, 16 E. Well No. API No. (YR DRLD/PRE '67) Footage from Section Line Type of Well (i.e. FSL = Feet from South Line) (Oil/Gas/INJ/WSW) Well Status (PROD/TAD/Abandoned) #- 1 #-1 4t- / Circle Circle U/N 3630 FNL 1 FWL TN.T /5-49A0201/04 v 4290 FNL 1485 EDFWL Oil f 6.-0$ / U/N 3960 NL 1485 WL Oil :4 U/N 3630 FNL 1485 FWL Oil #-4 U/N 3300 #-5 Pr_b_d FNL 1485 Oil FWL, tioo U/N FNL1815 FWL Oil A separate sheet may be attached if necessary * When transferring a unit which consists of more than one lease please file a separate side two for each lease. If a lease covers more than one section please indicate which section each well is located.

5 KANSAS CORPORATION COMMISSION OIL & GAS CONSERVATION DIVISION REQUEST FOR CHANGE OF OPERATOR TRANSFER OF INJECTION OR SURFACE PIT PERMIT Form T-1 April 2004 Form must be Typed Form must be Signed All blanks must be Filled Check Applicable Boxes: W S B Oil Lease: No. of Oil Wells TIalk-Eterwn- ** 0 Gas Lease: No. of Gas Wells E Gas Gathering System: Saltwater Disposal Well - Permit No. Spot Location. feet from Li N / S Line feet from Ti EI 111W Line a Enhanced Recovery Project Permit No E -2 3, 340 Entire Project: 0Yes Ibtio Number of Injection Wells Field Name. on P Vilas ** Side Two Must Be Completed. august 22,2005 Effective Date of Transfer: KS Dept of Revenue Lease No Lease Name: Sargent - -NE* sec. 3 6 Twp. 27 R 1 6 pieillw Legal Description of Lease. WI NE1 County. Wilson Production Zone(s): Squirrel,, Injection Zone(s). Squirrel Surface Pit Permit No feet from TIN, S Line of Section (API No. if Drill Pit, WO or Haul) feet from E E / W Line of Section Type of Pit: 0 Emergency 0 Burn n Settling El Haul-Off Workover n Drilling Past Operator's License No Contact Person- Dick Cornell Past Operator's Name & Address. Heat Can Oil, LLC Phone RECEIVED P.O. Box 223, Chanute, KS Date: Oct 200 ANSAS CORPORATION COMMISSION Title: Cnnslil tarrl-- Signature. Z e---scder.- OCT cli i sc.-43,230 New Operator's License No. f ontact Person: Henry M. JeWSSErITA, he) ICH KS New Operator's Name & Address Vsj- 2, n.a. Si- Phone- Z q49 / ein.a"...ea6 Lt./to Jesseph Oil Well Services Oil/Gas Purchaser By: Affidavit of Non-Production Date' TION DIVISION Title: Signature. Acknowledgment of Transfer: The above request for transfer of injection authorization, surface pit permit # has been noted, approved and duly recorded in the records of the Kansas Corporation Commission. This acknowledgment of transfer pertains to Kansas Corporation Commission records only and does not convey any ownership interest in the above injection well(s) or pit permit. is acknowleged as the new operator and may continue to inject fluids as authorized by Permit No.: Recommended action. is acknowleged as the new operator of the above named lease containing the surface pit permitted by No.: Date- Authorized Signature DISTRICT EPR PRODUCTION UIC Mail to: Past Operator New Operator District Mail to: KCC - Conservation Division, 130 S. Market - Room 2078, Wichita, Kansas Date: Authorized Signature

6 KDOR Lease No Side Two Must Be Filed For All Wells * Lease Name: Loc atin?" N lig Well No. API No. (YR DRLD/PRE '67) Footage from Section Line (i.e. FSL = Feet from South Line) Type of Well Well Status (Oi I/Gas/I NJ/WSW) (PROD/TA'D/Abandoned) Circle..s tep6efwl Z I //3q FQFNL J." I 15-2-if;6 25-2Se. 59 ta0cfnl.v -1-) PYDc 't ero j LS- Aos-- 5-2S7 31P NL FWL *1- I 5 IS ,162, 3 5'6,0 s3./ FNL Zo o 3 3_44 3L-FNL 1 `18's- 0./FWL NAl FE FWL 0.1 f2vt o o 0 FNL Lf 21> o FNL 4 FWL CL Peb 11:(2.&FWL 6 LC) I: Rce, PSUFNL A separate sheet may be attached if necessary When transferring a unit which consists of more than one lease please file a separate side two for each lease. If a lease covers more than one section please indicate which section each well is located.

7 AFFIDAVIT OF NON-PROD STATE OF KANSAS, COUNTY OF qt.osvio.. li,... Wilson County Register of Deeds I= 287 Page: 496 = U 00.C Total Fees: SUB g2 0., PA/25/ :64:52 AM, = C-, tn at. lip-linct c ivrzt c,..o.vs C-,Wcag- 5,-4 HENRY M. JESSEPH, of lawful age, being ili waeduly sworn on m o D o his oath states that he is familiar with the following described property, to-wit: The West Half of the Northeast Quarter (W/2 NE/4) of Section Thirty-six (36), Township Twenty-seven (27) South, Range Sixteen (16) East of the 6th P.M., Wilson County, Kansas; and personally knows that there has been no production of oil and/or gas upon said above described property, no deferred rental payments made thereon, no wells drilled thereon nor has there been any payments of guaranteed royalties thereunder for in excess of one (1) year. That because of failure of lessee to perform as provided in said lease, the following described oil and gas lease, to-wit: Oil and Gas Lease granted under date of April 22, 2003 to HEAT CAN OIL LLC., said lease being recorded in Book 259, Pages in the office of the Register of Deeds, Wilson County, Kansas; has by its own terms expired and is no longer of any force and RECEIVEu effect. KANSAS CORPORATION COMMISSIOI n *$ C=3 * = Do And further affiant says naught. HENRY NV JESSEP OCT C72 FONMVISION MITA. KS Subscribed and sworn to before me this a),),l day of Not Q,C7,21AARhotlh Public- E, tankelis- My Appointment Expires: NOTARY PUBLIC State of Kansas JYL E. UNREIN My Appt Exp liaaa

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