Chaparral Energy Encroachment Report

• Facility/Line Segment

• Conducted on

  Date

• Prepared by

• Location
  Address

• Name of Operating Company (or owner)

• Contacted by What Source

• Name of Contractor

• City/State/Zip

• Section/Township/Range

• County/State (if in Texas use block & survey)

Chaparral Energy Pipeline Data

• Facility Name

• Facility Code

• Mile #

• STK# or LAT/LONG

• Depth of Pipe

Foreign Crossing Data

• Type of Service

• Type of Material

• Outside Diameter

• Wall Thickness

• Type of Coating

• Working Pressure

• Depth Installed

• Catholic Protection

• Date Installed

  Date

• Test Lead Location

• Clearance Between Chaparral and Foreign Crossing (above or below)

• Remarks

• Is There a Maintenance/Atmospheric Corrosion Inspection

• Employee Signature

  Sign

• Date

  Date

• Supervisor Signature

  Sign

• Date

  Date