Well Data Form

Fields in bold are required

Subject:
Company Name:
Primary Contact:
Address:
City
Prov./State
Postal/Zip
Country
Phone No.
Fax No.
Email:
Do you have an immediate application for PARC400® Chemical?	Yes No
Brief description of inquiry:

1. Well #./Name:
2. Field Name:
3. Formation Type & Name:
4. Age of Well:
5. Estimated depth of Paraffin / Asphaltene:
6. Paraffin / Asphaltene in the flowline:	Yes No
7. Do you pig the flow line:	Yes No
8. Do you suspect formation plugging or damage due to Paraffin / Asphaltene:	Yes No
9. API gravity of oil:
10. Bottom hole temperature:
11. Bottom hole pressure:
12. Daily oil production bbl/m³:
13. Daily water production bbl/m³:
14. Daily gas production MCF/decs.:
15. Number of perforation zones:
16. Perforation depth from ft/m to ft/m:
17. Well T.D. ft/m:
18. Tubing T.D. ft/m:
19. Casing size = mm/inches:
20. Tubing size = mm/inches:
21. Packer in well:	Yes No
22. Pumping or flowing well:	Pumping Flowing
23. Type of pump used:
24. Oil & water produced up:	Casing Tubing
25. Open hole or casing:	Open Casing
26. Previous 6 month production history:
27. Drive mechanism:	Electric Gas Other
28. Previous treatments used:	Hot Oil Chemical None
29. Frequency of previous treatments:
30. Relative success of previous treatments:
31. Appx. Cost of previous treatments:
32. Is the well's hydrostatic pressure easilyoffset to inject treating fluid into the formation:	Yes No
33. Estimated amount of fluid and pressure to inject fluid into the formation: