Form WH-1 Supplement 3 "Well History and Work Resume Report" - Louisiana

What Is Form WH-1 Supplement 3?

This is a legal form that was released by the Louisiana Department of Natural Resources - a government authority operating within Louisiana.The document is a supplement to Form WH-1, Well History and Work Resume Report. As of today, no separate filing guidelines for the form are provided by the issuing department.

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Download a printable version of Form WH-1 Supplement 3 by clicking the link below or browse more documents and templates provided by the Louisiana Department of Natural Resources.

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FORM WH-1 Supplemental Page 3
FILE ONLY FOR WELLS THAT HAVE BEEN HYDRAULICALLY FRACTURE STIMULATED
SERIAL NO.
WELL NAME &
WORK PERMIT
NO.
NO.
OPERATOR
OPERATOR CODE
PART I
WATER SUPPLY INFORMATION
For hydraulically fractured wells, list below all water sources and corresponding water volumes used in drilling, completion, stimulation and workover
operations. (Direct questions to the Groundwater Resources Section at (225) 342-8242). NOTICE – No water obtained from a domestic well may
be used in E&P operations without prior Office of Conservation authorization.
DRILLING RIG SUPPLY
GROUND WATER SOURCE WELL #
OTHER WATER SOURCE
LOCATION (surface water sources only)
DRILLING RIG
SUPPLY
(DOTD or DNR #)
(Name of surface water body, public supply, etc.)
LATITUDE
LONGITUDE
VOLUME (gallons)
PUBLIC
PRIVATE
PUBLIC
PRIVATE
PUBLIC
PRIVATE
PUBLIC
PRIVATE
HYDRAULIC FRACTURE STIMULATION
GROUND WATER SOURCE WELL #
OTHER WATER SOURCE
LOCATION (surface water sources only)
STIMULATION
VOLUME (gallons)
(DOTD or DNR #)
(Name of surface water body, public supply, etc.)
LATITUDE
LONGITUDE
(hydraulic fracturing)
PUBLIC
PRIVATE
PUBLIC
PRIVATE
PUBLIC
PRIVATE
PUBLIC
PRIVATE
TOTAL GROUND
NO. OF
ARE ANY OF THE ABOVE WATER SOURCES UNDER A DNR ACT 955 SURFACE WATER USE C.E.A.?
WATER VOLUME USED
FRAC
YES
NO
IN ALL OPERATIONS
STAGES
IF YES, PROVIDE DNR C.E.A. #
(gallons)
OR CHECK THIS BOX IF C.E.A IS PENDING
CERTIFICATE: I certify that, to the best of my knowledge, all water used in operations conducted on this well are from the above listed sources and
these sources are being used for the above listed purposes in accordance with all applicable laws and regulations. I further understand that water
produced from domestic water wells shall not be used for these purposes without prior authorization by the Office of Conservation.
Signature:______________________________
Title: _
Date: _
__
PART II
HYDRAULIC FRACTURE STIMULATION INFORMATION
(ATTACH CONTINUATION PAGE(S) IF MORE SPACE IS NECESSARY)
YES
NO
WAS THE INFORMATION REQUIRED BY LAC 43:XIX.118 REPORTED TO A PUBLICLY ACCESSIBLE REGISTRY?
IF NO, USE THE AREA BELOW TO REPORT INFORMATION REQUIRED BY
LAC 43:XIX.118 OR ATTACH SERVICE COMPANY DOCUMENTATION
IF YES, PROVIDE THE NAME AND/OR WEB ADDRESS OF THE REGISTRY.
WHICH CONTAINS THIS INFORMATION.
BASE FLUID TYPE
BASE FLUID VOL (gallons)
MAX CONC. IN
MAX CONC. IN
TRADE NAME
SUPPLIER
PURPOSE
INGREDIENTS
CAS #
ADDITIVE (%
HF FLUID (%
by mass)
by mass)
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
CERTIFICATE: I certify that, to the best of my knowledge, all volumes, ingredients and concentrations reported above, included in the attached service
company documentation, or provided to a publicly accessible database, are correct to the best of my knowledge.
Signature:______________________________
Title: _
Date: _
__
FORM WH-1 Supplemental Page 3
FILE ONLY FOR WELLS THAT HAVE BEEN HYDRAULICALLY FRACTURE STIMULATED
SERIAL NO.
WELL NAME &
WORK PERMIT
NO.
NO.
OPERATOR
OPERATOR CODE
PART I
WATER SUPPLY INFORMATION
For hydraulically fractured wells, list below all water sources and corresponding water volumes used in drilling, completion, stimulation and workover
operations. (Direct questions to the Groundwater Resources Section at (225) 342-8242). NOTICE – No water obtained from a domestic well may
be used in E&P operations without prior Office of Conservation authorization.
DRILLING RIG SUPPLY
GROUND WATER SOURCE WELL #
OTHER WATER SOURCE
LOCATION (surface water sources only)
DRILLING RIG
SUPPLY
(DOTD or DNR #)
(Name of surface water body, public supply, etc.)
LATITUDE
LONGITUDE
VOLUME (gallons)
PUBLIC
PRIVATE
PUBLIC
PRIVATE
PUBLIC
PRIVATE
PUBLIC
PRIVATE
HYDRAULIC FRACTURE STIMULATION
GROUND WATER SOURCE WELL #
OTHER WATER SOURCE
LOCATION (surface water sources only)
STIMULATION
VOLUME (gallons)
(DOTD or DNR #)
(Name of surface water body, public supply, etc.)
LATITUDE
LONGITUDE
(hydraulic fracturing)
PUBLIC
PRIVATE
PUBLIC
PRIVATE
PUBLIC
PRIVATE
PUBLIC
PRIVATE
TOTAL GROUND
NO. OF
ARE ANY OF THE ABOVE WATER SOURCES UNDER A DNR ACT 955 SURFACE WATER USE C.E.A.?
WATER VOLUME USED
FRAC
YES
NO
IN ALL OPERATIONS
STAGES
IF YES, PROVIDE DNR C.E.A. #
(gallons)
OR CHECK THIS BOX IF C.E.A IS PENDING
CERTIFICATE: I certify that, to the best of my knowledge, all water used in operations conducted on this well are from the above listed sources and
these sources are being used for the above listed purposes in accordance with all applicable laws and regulations. I further understand that water
produced from domestic water wells shall not be used for these purposes without prior authorization by the Office of Conservation.
Signature:______________________________
Title: _
Date: _
__
PART II
HYDRAULIC FRACTURE STIMULATION INFORMATION
(ATTACH CONTINUATION PAGE(S) IF MORE SPACE IS NECESSARY)
YES
NO
WAS THE INFORMATION REQUIRED BY LAC 43:XIX.118 REPORTED TO A PUBLICLY ACCESSIBLE REGISTRY?
IF NO, USE THE AREA BELOW TO REPORT INFORMATION REQUIRED BY
LAC 43:XIX.118 OR ATTACH SERVICE COMPANY DOCUMENTATION
IF YES, PROVIDE THE NAME AND/OR WEB ADDRESS OF THE REGISTRY.
WHICH CONTAINS THIS INFORMATION.
BASE FLUID TYPE
BASE FLUID VOL (gallons)
MAX CONC. IN
MAX CONC. IN
TRADE NAME
SUPPLIER
PURPOSE
INGREDIENTS
CAS #
ADDITIVE (%
HF FLUID (%
by mass)
by mass)
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
CERTIFICATE: I certify that, to the best of my knowledge, all volumes, ingredients and concentrations reported above, included in the attached service
company documentation, or provided to a publicly accessible database, are correct to the best of my knowledge.
Signature:______________________________
Title: _
Date: _
__
WH-1 CONTINUATION PAGE - HYDRAULIC FRACTURE STIMULATION INFORMATION
PAGE
OF
(ATTACH CONTINUATION PAGE(S) IF MORE SPACE IS NECESSARY)
SERIAL NO.
WELL NAME &
WORK PERMIT
NO.
NO.
OPERATOR
OPERATOR CODE
MAX CONC. IN
MAX CONC. IN
TRADE NAME
SUPPLIER
PURPOSE
INGREDIENTS
CAS #
ADDITIVE (%
HF FLUID (%
by mass)
by mass)
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
CERTIFICATE: I certify that, to the best of my knowledge, all volumes, ingredients and concentrations reported above, included in the attached service
company documentation, or provided to a publicly accessible database, are correct to the best of my knowledge.
Signature:______________________________
Title: _
Date: _
__
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