OHIO DEPARTMENT OF NATURAL RESOURCES DIVISION OF OIL & GAS RESOURCES MANAGEMENT

2045 MORSE RD., F-2, COLUMBUS, OH 43229-6693 Phone: (614) 265-6922 • Fax: (614) 265-6910

SURFACE CASING AFFIDAVIT

DNR—744-1009 (REV 102011) Page 1 of 1

DNR-744-1009 (REV 102011)

 

 

hereby certifies that the casing in the well know by Permit Number , County, Township, Well No. was set on the day of , 20 and met or exceeded the following requirements:

1. the casing was constructed of good and sufficient wrought iron or steel a steel and was free of apparent defects;

2. the casing was set at least fifty (50) feet below the deepest underground source of freshwater (less than 10,000 mg/L total dissolved solids or less than 5,000 mg/L chlorides);

3. the casing was sealed with cement or prepared clay by pumping the sealing material down the inside of the surface casing and up through the annulus between the casing and the borehole wall with cement or prepared clay circulated to surface; and

4. no cement baskets were set above the required surface casing depth. (see #2 above)

***A copy of the service company’s field report may accompany this affidavit*** IN WITNESS WHEREOF, ___________________, through its principal, or authorized agent, has signed this instrument, this ___________ day of ______________. ___________________________________ (Name of Company) By: ___________________________________ (Signature) ___________________________________ (Title) STATE OF OHIO :SS COUNTY OF _______________ Before me, a Notary Public, in and for said County and State, personally appeared __________________________ as ____________________________ (Name) (Title) for ____________________________________, who being first duly sworn (Name of Company) subscribed to the foregoing instrument, and acknowledged that the same act was

the act of ___________________________ and that he executed the same as the (Name of Company)

act of such corporation for the purpose therein expressed, and in the capacity therein stated. IN TESTIMONY WHEREOF, I have hereunto set my hand and official seal at __________________________, Ohio, this _____________ day of ________________, (SEAL) ____________________________________ (Notary Public) ______________________________________________________________________________________

¨ The above requirements have been met. ___________________________________ (Signature)

¨ The above requirements have not been fulfilled. ___________________________________ (Signature)