Form Uic 10A – Fill Out and Use This PDF

ANNUAL DISPOSAL/ INJECTION WELL MONITORING REPORT

UIC-10A FOR CALENDAR YEAR

ORGANIZATION NAME & ADDRESS		ORGANIZATION ID
WELL NAME & NUMBER	SERIAL NO.	PARISH
FIELD	FIELD ID	SECTION	TOWNSHIP	RANGE

1. MONTHLY INJECTION RECORD:

A DEFAULT VALUE OF ZERO (0) HAS BEEN ENTERED INTO EACH FIELD. IF NECESSARY, REPLACE THE VALUE WITH THE APPROPRIATE NUMERIC VALUE FOR EACH MONTH.

INJECTION PRESSURE		ANNULUS PRESSURE		INJECTION RATE		VOLUME INJECTED
	(PSI)		(PSI)	(GALLONS PER MINUTE)
AVERAGE	MAXIMUM	MINIMUM	MAXIMUM	AVERAGE	MAXIMUM	BBL	MCF

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

TOTAL

2. WELL TYPE:

3. WELL COMPLETION:

4. TYPE OF FLUIDS INJECTED DURING REPORTING CYCLE:

5. COMMUNITY SWD INFO: (IF YES FOR A OR B, COMPLETE THE SECOND PAGE OF THIS FORM AND PROVIDE ATTACHMENTS.)

CERTIFICATION

I certify under penalty of law that I have personally examined and am familiar with the information submitted in this report and all attachments, and that based on my personal knowledge or inquiry of those individuals immediately responsible for obtaining the information, I believe that the information is true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment. (L. R. S. 30:17)

COMMUNITY SALTWATER DISPOSAL WELL/SYSTEM

NOTIFICATION/CERTIFICATION

Community Saltwater Disposal Well or System is a saltwater disposal well within an oil or gas field which is used by operators in the field or adjacent fields for disposal of their produced water.

1.Saltwater is transported to this community well by:

2.Certification:

I,_____________________________________________,___________________________________________,

(Name of Company Official)

(Title)

hereby certify that the information contained herein is accurate and complete to the best of my knowledge. I further certify that the community disposal well and system identified herein is a noncommercial operation and that operators using the system share only in the cost of operating and maintaining the well, related storage tanks, and equipment.

__________________________________________________	______________________________
(Signature)	(Date)

3.Attach one (1) copy of all signed agreements for disposal of produced saltwater. Such agreements must contain wording acceptable to the Commissioner and indicate compliance with the certification in 2. above.

NOTE: This community well notification/certification replaces the annual filing of Form UIC-13.

FORM UIC-10 INSTRUCTIONS

LAC 43:XIX.417 (Statewide Order No. 29-B), requires that the Operator of Record during a calendar year submit an annual report for each Class II disposal/injection well within Louisiana. For reporting, an operator may use either Form UIC-10, a well specific form sent from this office each February, or Form UIC-10A from our website at http://www.dnr.state.la.us/cons/documents.ssi .

A COMMUNITY SALTWATER DISPOSAL WELL / SYSTEM NOTIFICATION / CERTIFICATION, (second page of FORM UIC-10 and FORM UIC-10A) replaces the need for filing FORM UIC-13 annually, after the initial FORM UIC-13 is on record.

Commercial SWD facilities are not required to complete the Source Fluid Attachment sheet of manifested fluids, however, this sheet must be completed for any non-manifested fluids such as fluids received by pipeline.

Return the completed forms by May 31st, of the following year or 30 days after an Operator Change or P&A. Failure to comply with this will result in the issuance of a Compliance Order imposing a civil penalty of $200 for each delinquent report.

If you have questions, call Mr. Pierre Catrou at (225) 342-5567 or Ms. Glynis Coleman at (225) 342-7231.

SOURCE FLUID ATTACHMENT INSTRUCTIONS

1)Enter the injection well serial number, well name and number, organization/operator name, organization ID, and number the pages.

2)All fluids injected into the subject well must be reported according to Source Type. There are four categories of Source Types which are defined as follows:

○Source Type A - produced fluids from oil and gas production wells operated by your organization located within the field in which the subject injection well is located.

○Source Type B - produced fluids from oil and gas production wells operated by your organization located in fields other than the field in which the subject injection well is located.

○Source Type C - produced fluids from oil and gas production wells operated by organizations other than yours.

○Source Type D - fluids from wells and other sources that cannot be identified by an Office of Conservation LUW code. These fluids include but are not limited to gas plant waste waters not classified as hazardous, brine produced from hydrocarbon storage and brine wells in salt domes, out of state oil and gas production wells, offshore-federal oil and gas production wells, etc.