(Fill in the above box only if you wish someone other than the well owner to receive all correspondence.)
(If correspondence is being sent to a large organization, insert the specific person's name to whom you wish it directed.)
Expected Production During the Next 12 Months:
*Provide detailed description of intended use.
If commercial or industrial, describe type of business, number of employees, type of product produced or sold, etc.
If for new house or development, include construction start date.
If agricultural, include crop type and acreage:
Status of this well as of given date:
If this well is to be placed in aggregate with other permitted wells, give lead well number of aggregation.