Form BSEE-0133 WELL ACTIVITY REPORT

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Overview

0133 pg 1
0133 pg 2
0133 pg 3

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Sheet 1: 0133 pg 1

U.S. Department of the Interior

OMB control Number 1014-0018

Bureau of Safety and Environmental

Submit ORIGINAL

OMB Approval Expires xx/xx/xxxx

Enforcement (BSEE)

WELL ACTIVITY REPORT

BEGINNING DATE:

ENDING DATE:

REPORT IS NOT TO EXCEED 7 DAYS (1 WEEK) IN DURATION

CORRECTION

CHECK IF THIS IS THE LAST WELL ACTIVITY REPORT

GENERAL INFORMATION

1. API WELL NO. (10 digits)

2. OPERATOR NAME

3. WELL NAME

4. SIDETRACK NO.

5. BYPASS NO.

6. CONTACT NAME / CONTACT TELEPHONE NUMBER / CONTACT E-MAIL ADDRESS

7. RIG NAME OR PRIMARY UNIT (e.g., wireline unit, coil tubing unit, etc.)

8. WATER DEPTH (surveyed) (ft)

9. ELEVATION AT KB (Surveyed) (ft)

10. CURRENT WELLBORE INFORMATION

SURFACE

BOTTOM

LEASE NO.

AREA NAME

BLOCK NO.

LEASE NO.

BLOCK NO.

WELLBORE

START DATE

TD DATE

STATUS

END DATE

KOP (MD)

MD

TVD

MW PPG

LAST BOP TEST DATE

LAST BOP TEST PRESSURE

LOW

HIGH

11. WELLBORE HISTORICAL INFORMATION

WELLBORE

BOTTOM LEASE

START DATE

TD DATE

PA DATE

FINAL MD

FINAL TVD

BSEE Form BSEE-0133 (Sept./2020 - Supersedes all previous versions of this form which may not be used.) Page 1 of 3

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Sheet 2: 0133 pg 2

WELL ACTIVITY REPORT

12. CASING / LINER / TUBING RECORD

TUBULAR TYPE

HOLE SIZE (IN)

SIZE (IN)

WEIGHT (#/ft)

GRADE

TEST PRESSURE (psi)

SHOE TEST (EMW)

SETTING DEPTH (MD)

CEMENT QUANTITY (cubic ft.)

TOP

BOTTOM

13. WELL ACTIVITY SUMMARY

Provide a daily summary of well activities.

14. Open Hole Log Data

BSEE's Technical Data Management Section requires an Open Hole Well Report (Form BSEE-0133S) to accompany this Well Activity Report if any of the below conditions have occurred for this wellbore during this period:

None of the following have occurred:

Any of the above have occurred; if checked then submit Form BSEE-0133S.

15. Significant Well Events

Please check as many events from the list below:

Kick Occurrence

Well Control Equipment Failure

Shallow Water Flow

H2S Encounter

Weather and Oceanographic Conditions

New Technology Failure

General Rig Equipment Failure

Stuck Pipe

Lost Returns

Wellbore Integrity Failure

Station Keeping Failure

Other

BSEE Form BSEE-0133 (Sept./2020 - Supersedes all previous versions of this form which may not be used.) Page 2 of 3

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Sheet 3: 0133 pg 3

WELL ACTIVITY REPORT

Please provide narrative information with regards to any significant events. Provide attachments, if necessary.

MMS:

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 criminal penalties under 18 U.S.C. 1001.

Name and Title: ___________________________________________________ Date: __________________________

PAPERWORK REDUCTION ACT OF 1995 (PRA) STATEMENT: The PRA (44 U.S.C. 3501 et seq.) requires us to inform you that we collect this information to obtain knowledge of equipment and procedures to be used in drilling operations. BSEE uses the information to evaluate and approve or disapprove the adequacy of the equipment and/or procedures to safely perform the proposed drilling operations. 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 for Forms BSEE-0133 and BSEE-0133S is approximately 1 hour per form per response. This includes the 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 this form to the Information Collection Clearance Officer, Bureau of Safety and Environmental Enforcement, 45600 Woodland Road, Sterling, VA 20166.

BSEE Form BSEE-0133 (Sept./2020 - Supersedes all previous versions of this form which may not be used.) Page 3 of 3