| Form 21 |  Related  Doc |
| Date Submitted: | 5/4/2016 | MIT Assigned By: | |
| Date Recv'd: | 5/4/2016 | Facility ID: | |
| DocNum: | 401041421 | Facility Status: | |
| Operator Information: |
| Oper. No. | 16700 |
| Operator: | CHEVRON USA INC |
| Address: | 100 CHEVRON RD RANGELY CO 81648 |
| Type Of Facility: | | Well Status: |
| Facility Name | M.B. LARSON A |
| Operator contact: | DIANE PETERSON |
| Location: | | qtrqtr: | section: | township: | range: | meridian: |
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| MIT Details: |
| Test Type: | 5-YEAR UIC TEST |
| Test Date: | 5/3/2016 |
| Field Rep: | Browning, Chuck |
| Approved Date: | 5/5/2016 |
| Approved by: | |
| Last Approved MIT: | 6/14/2012 |
| Injection/Producing Formation Zones: | WEBR |
| Perforation Interval: | |
| Open Hole Interval: | 6495-6772 |
| Bridge/Cement Plug Depth: | |
| Tubing Size: | 2.875 |
| Tubing Depth: | 6511.5 |
| Top Packer Depth: | 6425 |
| Multiple Packers: | |
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| Condition of approval: |
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| Test Data: | Wellbore Channel Test: | | Reading Type | Pressure | | 10 MIN CASE | 1250 | | 5 MIN CASE | 1250 | | FINAL CASE | 1250 | | START CASE | 1250 |
| No channel test. |
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