DNR/OFFICE OF CONSERVATION ENGINEERING DIVISION ENG-16 Rev 5/11 (Formerly UIC-16) File in Duplicate with DISTRICT OFFICE TYPE OR OILFIELD WASTE DISPOSITION Operator Name: Operator Code: Mailing Address: ) - Contact Name: Well Name & No.: Serial No.: Field: Field Code: Location Type: Upland Elevated Wetland Section Township Range Submerged Wetland Water Location Date (If new well, enter date Total Depth reached. If Workover, enter date work Select One: New Well Workover over was completed): Was a Closed Mud System Utilized? Yes No Was a reserve pit Length: ft. constructed? Width: ft. Dimensions: Was pit closed? Yes No Yes Depth: ft. No Date Closed: Was a separate Length: ft. source pit Width: ft. Dimensions: Was pit closed? Yes No Yes constructed? Depth: ft. No Date Closed: Was the well drilled with fresh water mud which contains no more than 25 lbs/bbl Bentonite, .5 lbs/bbl “native” Yes No Caustic Soda or Lime, and 50 lbs/bbl Barite? Type, Volume & Disposition of Wastes Generated: Closed System Reserve Pit Type Volume Disposition* Volume Disposition* Water Based Mud Cuttings (water based) Oil Based Mud Cuttings (oil based) Completion Fluids Workover Fluids Sand Salt Water Wash Rainwater Other If Other, Describe: *Disposition on Instruction Page Comments: I, (Name of company official), hereby certify under penalty of law that I am personally familiar with the information submitted herein and that the disposition of all above-listed oilfield waste generated at this well location was conducted in accordance with all applicable rules and regulations of the Office of Conservation. Signature Date
DNR/OFFICE OF CONSERVATION ENGINEERING DIVISION ENG-16 Rev 5/11 (Formerly UIC-16) File in Duplicate with DISTRICT OFFICE TYPE OR OILFIELD WASTE DISPOSITION Operator Name: Operator Code: Mailing Address: Contact Name: ) - Well Name & No.: Serial No.: Field: Field Code: Section Township Range Location Type: Upland Elevated Wetland Submerged Wetland Water Location Select One: New Well Workover Date (If new well, enter date Total Depth reached. If Workover, enter date work over was completed): Was a Closed Mud System Utilized? Yes No Was a reserve pit constructed? Yes No Dimensions: Length: ft. Was pit closed? Yes No Width: ft. Depth: ft. Date Closed: Was a separate source pit constructed? Yes No Dimensions: Length: ft. Was pit closed? Yes No Width: ft. Depth: ft. Date Closed: Was the well drilled with fresh water “native” mud which contains no more than 25 lbs/bbl Bentonite, .5 lbs/bbl Caustic Soda or Lime, and 50 lbs/bbl Barite? Yes No Type, Volume & Disposition of Wastes Generated: Closed System Reserve Pit Type Volume Disposition* Volume Disposition* Water Based Mud Cuttings (water based) Oil Based Mud Cuttings (oil based) Completion Fluids Workover Fluids Sand Salt Water Wash Rainwater Other If Other, Describe: *Disposition on Instruction Page Comments: I, (Name of company official), hereby certify under penalty of law that I am personally familiar with the information submitted herein and that the disposition of all above-listed oilfield waste generated at this well location was conducted in accordance with all applicable rules and regulations of the Office of Conservation. Signature Date
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