1. Name and Mailing Address
2. Description of the Property
3. Parcel Number
4. Telephone Number of Person Completing Form
5. Individual Well Data
9. Natural Gas Policy Act Designation
10. Actual Gas Price Received for Well/Lease in December ($/Mcf.)
11. Gas BTU in This Well, Zone in This Well, or for This Lease
12. Proved Reserves
Proved Reserves
Well
Zone
Lease
Developed (MMcf.)
Undeveloped (MMcf.)
Date Estimate Made:
13. Reserve Calculation Method
Volumetric
Material Balance
Decline Curve
14. Present Contract Rate-of-Take
% Of Reserves (Mcf./day)
% Of Deliverability (Mcf./day)
15. Open Perforated Interval(s)
16. Cumulative Production as of Dec 31 (see instructions)
17. Bottom Hole Shut-In Pressure
Date Taken
18. Lease Summary
19. Gas Used on Lease (Mcf.)
20. Lease Condensate (Gals.)
($/Gal.)
21. Utility Sales Line Pressure (Psig)
22. Royalty Rate
23. If you checked “Government” in line 22, does this property qualify for a property tax exemption under revenue and taxation code
section 107.2 or 107.3?
24. Who Purchases the Gas Produced on This Lease?
25. What Is the Contract Expiration Date?
26. What Is the Date on Which Prices Become Renegotiable?
27. Basic Well Equipment
Producing Wells
Single Completions
Dual Completions
Triple Completions
With Equipment
No Equipment
Disposal Wells
Totals
28. Other Production Equipment
Total Original Cost Installed:
29. New Well, Redrill, Rework Report (see instructions regarding data required)
30. Remarks
