Form BSEE-0126 Well Potential Test Report

U.S. Department of the Interior Bureau of Safety and Environmental Enforcement (BSEE)

Submit original plus two copies, with one copy marked “Public Information.”

OMB Control Number 1014-0019 OMB Approval Expires xx/xx/xxxx

WELL POTENTIAL TEST REPORT (WPT)

1.  Original  Correction

4. LEASE NO.

3. WELL NO.

2. API NO. (with Completion Code)

11. OPERATOR NAME and ADDRESS (Submitting Office)

8. FIELD NAME

5. AREA NAME

6. BLOCK NO.

50. RESERVOIR NAME

88. TYPE OF REQUEST  INITIAL  RECOMPLETION  REWORK  RECLASSIFICATION  REESTABLISH

89. ATTACHMENTS PER    §§ 250.1151(a) and 250.1167  LOG SECTION  RESERVOIR STRUCTURE MAP  OTHER ____________

7. OPD NO.

10. BSEE OPERATOR NO.

43. DATE OF FIRST PRODUCTION

9. UNIT NO.

RESERVOIR CLASSIFICATION  SENSITIVE  NONSENSIITIVE

WELL TEST

92. DATE of TEST

93. PRODUCTION METHOD

94. TYPE OF WELL  OIL  GAS

95. HOURS TESTED

96. CHOKE SIZE (Test)

97. PRETEST TIME

98. CHOKE SIZE (Pretest)

99. SHUT-IN WELLHEAD PRESSURE (Gas wells only)

100. FLOWING TUBING PRESSURE

101. STATIC BHP(Omit on Public Info.Copy)

102. LINE PRESSURE (Gas wells only)

103. TOP PERFORATED INTERVAL (md)

104. BOTTOM PERFORATED INTERVAL (md)

TEST PRODUCTION - 24 HOUR RATES

105. OIL (BOPD)

106. GAS (MCFPD)

107. WATER (BWPD)

108. API @ 14.73 PSI & 60O F

109. SP GR GAS @ 14.73 PSI & 60O F

115. OTHER ACTIVE COMPLETIONS IN RESERVOIR (Continue in Remarks or attach an additional sheet if necessary.)

LEASE NO.

WELL NAME

API WELL NO.

LEASE NO.

WELL NAME

API WELL NO.

1.

5.

2.

6.

3.

7.

4.

8.

91. REQUESTED MAXIMUM PRODUCTION RATE (MPR) (Required only for Pacific and Alaska OCS Regions.)

26. CONTACT NAME

27. CONTACT TELEPHONE NO.

32. CONTACT E-MAIL ADDRESS

28. AUTHORIZING OFFICIAL (Type or print name)

29. TITLE

30. AUTHORIZING SIGNATURE

31. DATE

THIS SPACE FOR BSEE USE ONLY

REQUESTED MPR  ACCEPTED  REJECTED (Pacific and Alaska OCS Regions)

BSEE AUTHORIZING OFFICIAL

EFFECTIVE DATE

BSEE

FORM BSEE-0126 (Mo/Year - Replaces all previous editions of this form which may not be used.)

Page 1 of 2

WELL POTENTIAL TEST REPORT (WPT)

116. REMARKS
CERTIFICATION: I certify that the information submitted is complete and accurate to the best of my knowledge. I understand that making a false statement may subject me to the criminal penalties of 18 U.S.C. 1001. Name and Title: ________________________________________ Date: ________________________
PAPERWORK REDUCTION ACT STATEMENT: The Paperwork Reduction Act of 1995 (44. U.S.C. 3501 et seq.) requires us to inform you that this information is collected to implement the various environmental provisions of the OCS Lands Act. We use the information to determine well, lease, and field producing capability and serves as the basis for approving maximum production rates for certain oil and gas completions. Responses are mandatory (43 U.S.C. 1334). Proprietary data are covered under 30 CFR 250.197. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB Control Number. Public reporting burden of this form is estimated to average 5.25 hours per response, including the time needed to prepare the map, time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of the this form to the Information Collection Clearance Officer, Bureau of Safety and Environmental Enforcement, 381 Elden Street, Herndon, VA 20170.
BSEE	FORM BSEE-0126 (Mo/Year - Replaces all previous editions of this form which may not be used.)	Page 2 of 2