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STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION ANNULAR DISPOSAL APPLICATION 20 AAC 25. 080 1. Operator Name 3. Permit to Drill No 4. API Number 50- 5. Well Name 2. Address 6. Field 8. Stratigraphic description a Interval exposed to open annulus 7. Publicly recorded wells a All wells within onequarter mile b Waste receiving zone b water wells within one mile c Confinement 9. Depth to base of permafrost 10. Hydrocarbon zones above waste receiving 11. Previous volume disposed in annulus and date 12. Estimated slurry density 14. Estimated volume to be disposed with this request 13. Maximum anticipated pressure at shoe 15. Fluids to be disposed 16. Estimated start date 17. Attachments Well Schematic Include MD and TVD Cement Bond Log if required Surf* Casing Cementing Data FIT Records w/ LOT Graph Other 18. I hereby certify that the foregoing is true and correct to the best of my knowledge. Signature Printed Name Title Phone Number Date Commission Use Only Conditions of approval LOT review and approval Subsequent form required Approved by Form 10-403AD Rev*6/2004 Approval COMMISSIONER APPROVED BY THE COMMISSION INSTRUCTIONS ON REVERSE Submit in Duplicate Instructions to complete form 10-403AD Block No 1-6 Self-explanatory 7-8 When an additional annular disposal request is submitted for the same field list only the information that was not referenced in a previous disposal request. Operator Name 3. Permit to Drill No 4. API Number 50- 5. Well Name 2. Address 6. Field 8. Stratigraphic description a Interval exposed to open annulus 7. Publicly recorded wells a All wells within onequarter mile b Waste receiving zone b water wells within one mile c Confinement 9. Publicly recorded wells a All wells within onequarter mile b Waste receiving zone b water wells within one mile c Confinement 9. Depth to base of permafrost 10. Hydrocarbon zones above waste receiving 11. Previous volume disposed in annulus and date 12. Depth to base of permafrost 10. Hydrocarbon zones above waste receiving 11. Previous volume disposed in annulus and date 12. Estimated slurry density 14. Estimated volume to be disposed with this request 13. Maximum anticipated pressure at shoe 15. Estimated slurry density 14. Estimated volume to be disposed with this request 13. Maximum anticipated pressure at shoe 15. Fluids to be disposed 16. Estimated start date 17. Attachments Well Schematic Include MD and TVD Cement Bond Log if required Surf* Casing Cementing Data FIT Records w/ LOT Graph Other 18. Fluids to be disposed 16. Estimated start date 17. Attachments Well Schematic Include MD and TVD Cement Bond Log if required Surf* Casing Cementing Data FIT Records w/ LOT Graph Other 18. I hereby certify that the foregoing is true and correct to the best of my knowledge. Signature Printed Name Title Phone Number Date Commission Use Only Conditions of approval LOT review and approval Subsequent form required Approved by Form 10-403AD Rev*6/2004 Approval COMMISSIONER APPROVED BY THE COMMISSION INSTRUCTIONS ON REVERSE Submit in Duplicate Instructions to complete form 10-403AD Block No 1-6 Self-explanatory 7-8 When an additional annular disposal request is submitted for the same field list only the information that was not referenced in a previous disposal request. .

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