Near Miss Reports

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 Injury Date Injury Time State Township/City Pad Latitude Longitude 911 Address Weather Well Lease Well Number Well Field Personnel/Witness Name Company Position Days Into Hitch Years With Company Years In Oil/Gas Personnel/Wittness Phone Task Summary Witness Name Witness Statement Contributing Factors Notification Timeline Corrective Action Photos & Videos Supervisor Name Supervisor Email Supervisor Phone Supervisor Office Phone HSE Name HSE Email HSE Phone HSE Office Phone Comp. Man Name Comp. Man Email Comp. Man Phone Comp. Man Office Phone NNE Name NNE Email NNE Phone NNE Office Phone NNE HSE Name NNE HSE Email NNE HSE Number NNE HSE Office Phone SUBMITTEE
07/03/201708:53 PMWVBlacksvilleYank Hollow Road Dave Dillie's trailerBlacksville

I received a complaint from Dave Dillie on July 3,2017. He alleges NNE has caused the floor in his trailer to start to wave, He said he checked the frame, where he could access it with the level, but agreed the frame was level. The allegations started that by drilling under it we changed the water table, which then caused the trailer to settle. After further discussion and the talking through the process of drilling, he claimed it was the sand truck traffic beating on the ground that caused the trailer to settle. I told him I would discuss it with the office and we would get back to him. 7-6-2017 I went out to look at the fence that we needed to reinstall and his daughter asked what we had decided on the trailer. I told her the issue was still being discussed and we would get back to them. Mrs, Dillies cell phone #304-692-5613

Andy Travis
08/28/201809:15 AMWVBlacksvilleYost39.641739-80.2182173589 Daybrook Rd. Fairview, WV 26570Clear and Sunny, HotYost7HBlacksvillewill AbrahamBills BitsDriver(412) 518-8405

Delivering soap tote to location

As the Bill's Bit service driver(William Abraham - (412)518-8405) was pulling onto a congested location, he thought he could squeeze through a tighter spot with his truck and trailer and grazed the bumper of a parked pickup truck belonging to a floorhand(Grover Clawson - (740)434-32432).

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Congested location, impatience/in a hurryNotified immedietley after everyone was confirmed safe/ok.Drivers swapped out insurance information and phone numbers.00000000000 0000000000Email hidden; Javascript is required.(000) 000-0000(000) 000-00000000000000 000000000000Email hidden; Javascript is required.(000) 000-0000(000) 000-0000Josh GrimEmail hidden; Javascript is required.(304) 276-3899(000) 000-0000Jay HewittEmail hidden; Javascript is required.(304) 382-1825(000) 000-0000Andy TravisEmail hidden; Javascript is required.(304) 951-0909(304) 212-0415
10/03/201710:45 PMWVBlacksvilleBlacksville

At 6:45 pm an Aveda truck driver was unloading his last load of the day unassisted and without authorization. As the pump for the rig was being hoisted up the roller board the line broke dropping the pump approximately 7'. No one was in the area but the pump sustained damage. It bent the skid, which throws the pump out of alignment, damaged the electrical motor and damaged the gear end. It will be about four days before a replacement can be put together.

The employee has been terminated for not listening to instructions and going against policies of all three companies involved. After the incident a safety stand down was preformed.

Andy Travis
04/30/201701:36 AMWVBlacksvilleBlacksville

At 21:36 hrs we had an incident while running 5.5 production casing. After latching up a joint of casing on the cat walk with the elevators the Driller began to pick up the joint during that time he floated his elevators back in as normal. At the same time the derrick hand that was operating the cat walk and skate, ran the skate up to far and pushed the joint of casing thru the elevators into the back of the derrick. The driller could not see that the casing had went into the back of the derrick underneath one of the 4X4 beams in the top drive track. The casing struck the beam while coming up and ripped it free from the I beams of the top drive track, the 4X4 beam fell to the floor landing on the rotary table. Kimzy casing crew had 3 men that were working on the floor where the beam fell to the floor, they saw it happen and were able to dive out of the way of the beam before it came to the floor.

Myself and the Rig Manager heard the incident happen and immediately went to the rig floor to assess the situation and ensure no one was injured (no injuries). It was found that the top drive track had suffered damage and was bent to the point that the top drive could not come to the floor. (Jay Hewitt was contacted at this time)( Brent Kasmiear Nabors superintendent)

We held a safety stand down to allow the personal to calm down and come up with a plan to remove the joint of casing that was still latched in the elevators. Once a plan was in place we removed the joint of casing and rigged down the casing crew and began circulating the casing.

Andy Travis
11/13/201702:00 PMWVBlacksvilleBlacksville

Travis was dumping onto the stockpile with A John Deere 250 Artic rock truck. he was slightly downhill, when he dumped the load, the load did not slide out of the truck and it tilted the cab over. there were no injuries and minimal damage to truck.

Andy Travis
08/14/201707:30 AMWVBlacksvilleKassay Pad/DTE InterconnectBlacksville

DTE's pipeline has a pressure release valve at the interconnect below the Kassay Pad. The valve is set to "pop off" at 1200 psig. Our Kassay pad has a pressure safety high on our pad set at 1150 psig. So, our pad should shut in before the pressure release valve goes off shutting in our pad. The pressure safety high had been disabled and the pressure on the pipleline got above 1200 psig, causing the pressure relief valve to actuate. This venting of gas startled the water truck drivers and they ESD's the pad, which was the correct form of action. Going forward the pressure safety high on the pipeline pressure for the Kassay pad will not be disabled.

Andy Travis
04/11/201805:15 PMWVBlacksvilleJenkins39.7162-80138073726 Mason Dixon Hwy Morgantown, WV 26541Clear and breezy, 50°JenkinsmoveBlacksvilleandy travis(000) 000-0000

After loading the Strad upright tanks to be taken back to the Strad yard

After loading the Strad upright tanks to be taken back to the Strad yard, one of the trucks struck a low phone line along route 7. The pilot car noticed the low line and tried to notify the driver(Jamie Jones 304-488-6978) but the driver never heard the notification and continued through snagging the line and breaking it. Immedietley afterwards Timothy James notified his HSE, the Utility company, and myself.

00000 00000low lines/ faulty communicationNotified immediate after it everything was confirmed safeverify equipment is working properly or get a confirmation that the order was heard by driverTimothy "Cowboy" JamesEmail hidden; Javascript is required.(000) 000-0000(000) 000-0000Brent PhillipsEmail hidden; Javascript is required.(740) 502-1218(000) 000-0000Joshua GrimEmail hidden; Javascript is required.(304) 276-3899(000) 000-0000Jay HewittEmail hidden; Javascript is required.(304) 382-1825(000) 000-0000Andy TravisEmail hidden; Javascript is required.(304) 951-0909(304) 212-0415
10/09/201705:00 PMWVBlacksvilleBlacksville

A Day Brook truck hauling fresh water was attempting to pas a parked pickup when it slid off the road. The driver contacted Brad Chadwick and they anchored the truck with a tandem until another water truck could empty it out. Once empty they were able to drive the truck back on the road.

The pickup was not supposed to be parked in that location and the Day Brook driver should have not made the attempt with such little clearance.

Moving forward we will make sure no one parks along the lease road.

Andy Travis
05/07/201711:45 AMWVBlacksvilleBlacksville

While pressure testing for stage 20 on the Kassay 7H a wing ? on the back of one of the pumps failed catastrophically. Test pressure was 10,657 psig at the time of failure. No one was in the red zone during the incident.

Andy Travis
11/15/201709:30 AMWVBlacksvilleBlacksville

Ryan Emery from Backwoods Oil & Gas Services, Inc. had to move a light plant from the back of location to the front utiliziing a 12k telehandler. He picked up the light plant with the telehander forks near the back of location. Light plant picked ~2' off the ground. While driving behind the KSW backyard he bumped into Jordan Neville's white F150 with his forks that was parked along the AST containment, damaging the grille and hood. All red zones were in place while equipment was in operation and seat belts were utilized.

Andy Travis
09/05/201702:40 PMWVBlacksvilleBlacksville

A tandem from Lightening trucking was unloading the compressor off the bed, the bridal didn't have enough slack in it so it came off the ear of the skid. When it did the radiator of the compressor was bent. No one was in the red zone and no other equipment was damaged.

Andy Travis
03/22/201709:16 PMWVBlacksvilleI79 south 121 mile postBlacksville

While driving south on I79 in traffic. A piece of debri struck the windshield of my 2014 f150 on the passenger side causing a chip in the windshield I looked at the vehicles around me and did not notice any vehicles with excessive mud on them

Andy Travis
10/20/201711:15 AMWVBlacksvilleBlacksville

Today at approximately 1115AM a panhandle Casing truck was delivering 9 5/8? casing to the Coastal pad and on his way back through the fisher location, the rear of his trailer hooked the front fender of the Rig Managers truck pushing it into the safety shack. There are no injuries. The Panhandle truck was being driven by Gail See He has been driving tractor trailers since 2002. He is driving out of the Morgantown, WV dispatch phone

The red Chevrolet pickup is a Patterson company vehicle driven by Patterson #334 rig manager Jeff Donahue

Andy Travis
06/19/201704:58 PMWVBlacksvilleBlacksville

BJ Services employee was performing preventative maintenance on a fluid end. While making the repairs another employee asked him a question, he turned his head to answer the question and the plunger fell and struck him the foot. The injured employee was wearing steel toe/metatarsal boots, but still sustained an injury. The employee was taken to the supervisors truck, Axiom and BJ EHS were notified, first aid and icing the foot were recommended. The employee later decided to have an x-ray 6/22/2017, which revealed a hair line fracture.

Andy Travis
01/14/201810:45 PMWVBlacksvillePost Frac Move from Campbell Pad to Nine Energy LocationBlacksville

On January 14th at 10:45 PM while moving the Nine Energy grease trailer from the Coastal Pad up the steep hill towards the Fisher Pad, a dash light came on in the Nine Energy pickup truck indicating "Transmission Too Hot" and the engine shut off. The truck began coasting backwards downhill with no steering or brakes. The trailer turned and pulled the pickup into the ditch, then came free from the fifth-wheel ball, which parted the safety chains and the break-away latch. The pickup came to a stop in the ditch, while the trailer continued coasting downhill. The trailer remained upright as it rolled backwards and stopped right before the tree line approximately 70 yds from the lease road.

Dustin Merchant was the driver of the Nine Energy pickup. He is a hot shot driver for Nine. He was uninjured, but was taken to the hospital for examination. Dustin also underwent a drug and alcohol test last night and the results were ?negative?.

There were no releases involved with the incident. Damage to the pickup includes body damage, driveshaft and possible hidden damage. Damage to the PCE trailer appears to be minor. The trailer has been towed back to the lease road and inspected carefully. Both the truck and trailer have been removed from NNE property. Nine Energy's investigation is ongoing.

Andy Travis
10/03/201703:45 PMWVBlacksvilleBlacksville

I just received word from the field that one of the water truck drivers from Ransom Drilling was killed as a result of his truck wrecking. I?m told as he was traveling on Rt. 50 to/from one the disposal facilities in Ohio, the truck blew a tire and he lost control. DOT is on scene and will conduct an investigation. There is a story already on WBOY?s website with two pictures, as well as WDTV?s website.

Andy Travis
04/09/201708:00 PMWVBlacksvilleBlacksville

At approximately 1600 PM on 4/9/17, Best Line Equipment rentals was delivering a tele-handler to the Kassay Pad. The driver, Justin, had lowered his drop trailer and unloaded the tele-handler. Justin then attempted to raise his drop trailer. He then noticed the trailer was not working and had released approximately 15-20 gallons of hydraulic fluid onto the Kassay pad. The roustabout also noticed it at the same time and put a duck pond under the trailer. The roustabout continued to contain the hydraulic fluid and the driver reported it to me. We immediately contained with peat moss and began to dig up the fluid and put it a waste dumpster. We have contacted Max with NGE to evaluate the material and the cleanup. I have attached before pictures and we will follow up with after pictures when we can.

Non- Hazardous Release (Hydraulic oil approximately 15-20 gallons)
73 Degs, Clear and sunny no wind
Was placed in a Waste Container.
Pad was dry at the time of release.

Andy Travis
04/30/201910:30 AMWVClayBoggess39.670089-80.093496000000Boggess3HBlacksvilleRobert ForceEnerstarDriver(570) 494-6277

Hauling stallion trailer to Stallion yard from Boggess Pad.

Truck driver picked up a Stallion crew accommodation that was not being used after offloading a trailer at the Mateo pad. The driver exited the pad location and drove down to route 7. The AT&T fiber line was hanging low about 14' and the driver hit the line pulling the line anchor out of the power line post. The driver then turned left onto route 7 ignoring the posted NNE signage that say's (no left turns). The Pilot car company (X5O) did not high pole the line, reason unknown.

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Human errorImediateDriver no longer permitted onsiteJared 000Email hidden; Javascript is required.(570) 567-4237(304) 951-0909Andy TravisEmail hidden; Javascript is required.(304) 951-0909(304) 951-0909Troy HamidiEmail hidden; Javascript is required.(719) 459-2067(304) 951-0909Jay Hewitt IIEmail hidden; Javascript is required.(304) 382-1825(304) 951-0909Andy TravisEmail hidden; Javascript is required.(304) 951-0909(304) 212-0415
11/13/201710:30 AMWVBlacksvilleBlacksville

Kenneth Keeling, a Patterson UTI Motorhand was found passed out under the influence of alcohol in the passenger side front seat of a vehicle on location. Patterson UTI HSE was informed by rig manager Jeff Donahue) and a field sobriety check was performed. Kenneth blew over the legal limit. Patterson was let go and was taken to the airport by Patterson HSE.

Andy Travis
02/04/201802:30 AMWVBlacksvilleCoastal39deg 41' 42.2"80deg 13' 22.4"1003 Daybrook Rd, Fairview, WV 26570Evening, light snow, 25 degreesCoastal10HBlacksvilleAustin KnowldemProducersShort Service Employee70.51(740) 586-8690

Austin Knowldem was fueling body load frac pump 244

Austin Knowldem was fueling body load frac pump 244, when he made a misstep and fell from the truck. He landed on his hip. Axiom was called and Austin did not seek medical attention. At this time there is no reported injury and no trip to a medical facility.

Matt Umtied

Matt was on the blender when he witnessed Austin fall from the body load frac pump while fueling. He assisted Austin, and it was determined that medical attention was not necessary. Axiom was called. It has been reported that Austin did not seek medical attention.

Limited Visibility, cold weather, light snow, limited oil and gas experienceNNE company man was informed immediately and the incident was reportedA safety meeting was held reminding of the importance of foot placement and having a spotterincident-report1.pdfDan MullinsEmail hidden; Javascript is required.(740) 586-8690(740) 586-8690Ralph BoleyEmail hidden; Javascript is required.(740) 605-4457(740) 605-4457Mike InmanEmail hidden; Javascript is required.(989) 858-6112(989) 858-6112Criss VanGilderEmail hidden; Javascript is required.(405) 757-8725(405) 757-8725Andy TravisEmail hidden; Javascript is required.(304) 951-0909(304) 212-0415Criss VanGilder
04/12/202108:50 PMWVFairviewCummins39.66189880.1808911698 Yank Hollow Road, Fairview, WV 26570Cloud CoverCummins14/18BlacksvilleJohnna DickeyGMSGate Guard211(989) 858-6112

Frac Operations. Sand trucks delivering sand to pad

From Mike Inman
Last night around 8:50 PM, I received a text from a Daybrook driver. He asked what was wrong with the female at the lower guard shack. He said that she sounded panicked and had fear in her voice. The roustabout was also down there, he was working on the light plant for the lower guard shack. Ryan with PSC, and myself headed down there. The roustabout was returning to pad, he stopped me, and said that the female guard was scared and was having some issues. We arrived at the guard shack and you could tell she had been crying and was scared. The light plant had tripped out again and the shack had no power. Her boyfriend was also at the shack. I told him to leave and Ryan and myself asked her what was wrong.
She told us that Matt who drives the “Green Weenie” for AEP had caused her issue. She said that he had asked her for a cigarette. He said he would pay for it and she said that it was fine. She went into the shack to get the cigarettes. He came up the window, she handed the cigarette to him through the window. He then grabbed her wrist and said maybe I can fit through the window or something to that affect. She pulled away and said she would slam his hand in the window. Matt then left to go to pad with the load of sand. That is when the light plant died. She had very poor cell service, no CB, and no light. She had called her boyfriend who only was 20 mins away, she also put a crowbar in the shack with her. Matt was then leaving the pipe yard, he pulled up and said I hear you are having CB issues, but since you already have a guy here, I am not going to help you.
We then placed her at the Kassay Pad guard shack, Water transfer has a guy on the Kassay, and the roustabout also stayed at the Kassay pad. She felt safe with that. PSC contacted AEP and told Matt not to return to pad. The AEP dispatcher asked Matt what had happened, Matt said he just asked to buy a cigarette and it must be a conspiracy against him. It was also confirmed that his truck was on the in-out sheet that GMS maintains.
Johnna Dickey has worked for GMS for less than 2 weeks. Her Supervisor is Jeff Weimer at 304-216-7707. Keep in mind that she did not report this because she had only worked there for a short time and was concerned about her job. This was reported to us by other employees looking out for her. I also told her that if she ever felt threatened again, she should immediately drive to pad for help.
Matt Gaynor – driver for AEP. Truck Number #2795. AEP asked that the trailer and box to be dropped at the AEP yard in Washington.

Mike Inman

Last night around 8:50 PM, I received a text from a Daybrook driver. He asked what was wrong with the female at the lower guard shack. He said that she sounded panicked and had fear in her voice. The roustabout was also down there, he was working on the light plant for the lower guard shack. Ryan with PSC, and myself headed down there. The roustabout was returning to pad, he stopped me, and said that the female guard was scared and was having some issues. We arrived at the guard shack and you could tell she had been crying and was scared. The light plant had tripped out again and the shack had no power. Her boyfriend was also at the shack. I told him to leave and Ryan and myself asked her what was wrong.
She told us that Matt who drives the “Green Weenie” for AEP had caused her issue. She said that he had asked her for a cigarette. He said he would pay for it and she said that it was fine. She went into the shack to get the cigarettes. He came up the window, she handed the cigarette to him through the window. He then grabbed her wrist and said maybe I can fit through the window or something to that affect. She pulled away and said she would slam his hand in the window. Matt then left to go to pad with the load of sand. That is when the light plant died. She had very poor cell service, no CB, and no light. She had called her boyfriend who only was 20 mins away, she also put a crowbar in the shack with her. Matt was then leaving the pipe yard, he pulled up and said I hear you are having CB issues, but since you already have a guy here, I am not going to help you.
We then placed her at the Kassay Pad guard shack, Water transfer has a guy on the Kassay, and the roustabout also stayed at the Kassay pad. She felt safe with that. PSC contacted AEP and told Matt not to return to pad. The AEP dispatcher asked Matt what had happened, Matt said he just asked to buy a cigarette and it must be a conspiracy against him. It was also confirmed that his truck was on the in-out sheet that GMS maintains.
Johnna Dickey has worked for GMS for less than 2 weeks. Her Supervisor is Jeff Weimer at 304-216-7707. Keep in mind that she did not report this because she had only worked there for a short time and was concerned about her job. This was reported to us by other employees looking out for her. I also told her that if she ever felt threatened again, she should immediately drive to pad for help.
Matt Gaynor – driver for AEP. Truck Number #2795. AEP asked that the trailer and box to be dropped at the AEP yard in Washington.

Night time, isolated guard shackImmediateDriver was released from serviceCriss VanGilderEmail hidden; Javascript is required.(405) 757-8725(405) 757-8725Andy TravisEmail hidden; Javascript is required.(304) 212-0415(304) 212-0415Mike InmanEmail hidden; Javascript is required.(989) 858-6112(989) 858-6112Mike InmanEmail hidden; Javascript is required.(989) 858-6112(989) 858-6112Andy TravisEmail hidden; Javascript is required.(304) 951-0909(304) 212-0415Criss VanGilder
07/24/201904:30 AMWVFairview, WVMateo39°39'22.639"N80°11'57.351WYank Hollow Road Fairview, WV 26570Clear/70°FMateo6HBlacksvilleCody WillisPattersonFloors141.51.5(878) 228-1430

Pressure washing the driller side top sub.

While pressure washing the top sub on the drillers side of the floor, the door broke off of the hinges and fell to the ground roughly 20FT. Upon inspection the top hinge was found to be broken off for what appears to be a while due to the weathering and all that was holding the door on was the one inch piece of hinge on the bottom of the door. The impact of the water from the rig pressure washer was enough to finish breaking that hinge and the door than fell freely to the ground below. Approximate weight of the door is 80lbs. The area below the door was clear due to the buffer zone for the man lift.

Cody Willis

While pressure washing sub with man lift, water was sprayed onto the door on the top sub and the door fell off and to the ground roughly 20ft. There was nobody near where the door fell or in the buffer zone of the man basket.

CorrosionImmediatley after Being notified by the night rig manager Jason Bedell.Inspect hinges for signs of wear/corrosion/fatigueJason BedellEmail hidden; Javascript is required.(570) 766-6960(307) 480-0800Mario ElizondoEmail hidden; Javascript is required.(878) 228-1430(878) 228-1430Joshua GrimEmail hidden; Javascript is required.(304) 276-3899(304) 276-3899Josh DaltonEmail hidden; Javascript is required.(724) 825-6859(304) 241-5752Andy TravisEmail hidden; Javascript is required.(304) 951-0909(304) 212-0415
12/10/201809:00 AMWVMorgantownTesttesttest48 Donley StreettesttesttestBlacksvilleAndrew Travistesttest222(304) 241-0572

test

test

Andrew Travis

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testtesttestAndrew TravisEmail hidden; Javascript is required.(304) 241-0572(304) 241-0572Andrew TravisEmail hidden; Javascript is required.(304) 241-0572(304) 241-0572Andrew TravisEmail hidden; Javascript is required.(304) 241-0572(304) 241-0572Andrew TravisEmail hidden; Javascript is required.(304) 241-0572(304) 241-0572Andrew TravisEmail hidden; Javascript is required.(304) 951-0909(304) 212-0415Andy Travis
07/13/202102:45 PMWVBattelleERP Pipe line @ Pad39.67355296-80.273581231 Happy Lane Fairview, WV 26570clearERP Well Pad Water LineERP water lineBattelleRodney VarnerForquer ContractingForeman1022(304) 288-2337

Hauling logs to landing area with log skidder. Skidder upset.

Russell Beach (304) 692-9552 was operating a log skidder with a load of logs. The skidder upset on its side as a result of the heavy load and un even terrain.

Rodney Varner

"Dragging logs into landing he turned down road bank. The logs were still up on road and he lifted back of skidder up. Skidder fell onto its side"

Heavy load. Un level ground30 minutesDo not turn sharp with loads. Smaller loads.Mike ReedEmail hidden; Javascript is required.(304) 288-2337(304) 879-5251Jordy ForquerEmail hidden; Javascript is required.(304) 216-5172(304) 879-5251Mike ShreveEmail hidden; Javascript is required.(304) 918-3050(304) 212-0432David McDougalEmail hidden; Javascript is required.(304) 941-5033(304) 212-0419Andy TravisEmail hidden; Javascript is required.(304) 951-0909(304) 212-0415Dave McDougal
09/18/201812:00 PMWVBlacksvilleMepco39 39 45.9380 09 07.77579 Mepco Road, Fairview, WV 26570Rain overcastMEPCOLease RdBlacksvilleMichael KnightExport FuelDriver553(724) 610-1532

Driver had just offloaded fuel on the Mepco pad and was leaving on the lease rd. The driver stated he reached down for his Pepsi and the truck dropped off the left side of the road and bottomed out in the ditch line. Hillbilly towing was called and was able to remove the fueler from the ditch.

Driver had just offloaded fuel on the Mepco pad and was leaving on the lease rd. The driver stated he reached down for his Pepsi and the truck dropped off the left side of the road and bottomed out in the ditch line. Hillbilly towing was called and was able to remove the fueler from the ditch. No injuries, environmental releases, vehicle, or property damage.

Shane Stephenson

Driver had just offloaded fuel on the Mepco pad and was leaving on the lease rd. The driver stated he reached down for his Pepsi and the truck dropped off the left side of the road and bottomed out in the ditch line. Hillbilly towing was called and was able to remove the fueler from the ditch.

Not paying attentionImmediatelyDriver will not return to location. Safety meeting was held discussing driver safetyShane StephensonEmail hidden; Javascript is required.(405) 757-8725(405) 757-8725Shane StephensonEmail hidden; Javascript is required.(405) 757-8725(405) 757-8725Eric BooneEmail hidden; Javascript is required.(304) 377-6666(304) 377-6666Andy TravisEmail hidden; Javascript is required.(304) 951-0909(304) 212-0415Andy TravisEmail hidden; Javascript is required.(304) 951-0909(304) 212-0415Criss VanGilder
 Injury Date Injury Time State Township/City Pad Latitude Longitude 911 Address Weather Well Lease Well Number Well Field Personnel/Witness Name Company Position Days Into Hitch Years With Company Years In Oil/Gas Personnel/Wittness Phone Task Summary Witness Name Witness Statement Contributing Factors Notification Timeline Corrective Action Photos & Videos Supervisor Name Supervisor Email Supervisor Phone Supervisor Office Phone HSE Name HSE Email HSE Phone HSE Office Phone Comp. Man Name Comp. Man Email Comp. Man Phone Comp. Man Office Phone NNE Name NNE Email NNE Phone NNE Office Phone NNE HSE Name NNE HSE Email NNE HSE Number NNE HSE Office Phone SUBMITTEE