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Form3160.3 <br />(August 2007) <br />UNITED STATES <br />DEPARTMENT OF THE INTERIOR <br />BUREAU OF LAND MANAGEMENT <br />FORM APPROVED <br />ONB No.10DOW <br />Expires July 31, 2010 <br />5. Lease Serial No. <br />C- 0118327 <br />APPLICATION FOR PERMIT TO DRILL OR REENTER I if tndrarm Allotee or Tribe Name <br />na <br />Ia. Type of work: [Z]DRILL REENTER <br />7 If Unit or CA Agreement, Name and No. <br />Natural Soda, Ina <br />b. Type of Well: CO Well Gas Weli Other 13 Single Zone El Multiple Zone <br />S. Lease Name and Well No. <br />15H-R <br />2 Naive of Operator Natural Soda, Ina <br />9. API Well Na <br />na <br />3a. Address 3200 Rio Bianco County Road 31 13b, <br />Plone Na (mrhrde area co*) <br />10. Field and Pool, or Exploratory <br />Rifle, CO 81650 1 <br />(970) 878 -3874 <br />Boles Bed, Nahcolite <br />4. Location of Well (Report loearmri edewiy ad in aeo nkm wiui airy Store mps,000. *) <br />11. Sea, T. R M. or Blk. and Survey or Area <br />At surface Latitiude 39.926904068 N Longitude 1011371327792 W, NAD83 <br />SHL: Sec 34. T1 S. R98W, 6th P.M. <br />At proposed prod. zone <br />14. Distance in miles ad dim6en from nearest town or past olfee <br />12. County or Parish <br />13. State <br />— 45 miles southwest of Meelter Colorado <br />Rio Blanco <br />CO <br />15, Distance fine unrest 125 B. <br />location >Q nearest <br />16 8of acres in lase <br />8382 <br />17. Spacing Unit dedicated to this well <br />property or lase line, 8 <br />Also tonamst ft unit line, if any) <br />I& Distance from proposed location* 69% <br />to narest wdl, drilling, completed, <br />19. Proposed Depth <br />20. BLM/BIA Baud Na on file <br />applied for, on this lease, ft. <br />-2418 ft. MD <br />—1827 RTW <br />21 Elevations (Show whether DF, KM RT, (L, etc.) <br />22 Approximate date work will start* <br />23. Estimated duration <br />GL <br />07/0612015 <br />28 days <br />24. Attachments <br />The following, completed in accordance with the requirements of Onshore Oil and Gas Order No. 1, must be attached to this &m <br />- <br />1. Well plat certified by a registered surveyor. 4. Bond to cover the operations unless covered by an existing bond on file (see <br />2 A Dulling Plan. Item 20 above). <br />3. A Surface Use Plan (if the location is on National Fort System Lands, the 5. Operator certification <br />SUPO must be filed with the apprapriate Forest Service Office). 6. Such other site specific information and/or plans as may be required by the <br />BLM. <br />Title Sigaattae f Name (PriruedlTYPed1 Date <br />.,•�_'` (f —v r Gerald Daub %..2 "" �! •' .`S <br />True <br />President, Daub & Associates, lna <br />AI4roved by f2puti-e) Nave M'*0ed/TYped} Date <br />Title I Office <br />Application approval does not warrant or certify that the applicant folds legal of equitable title b those rights in the subjectlease which would entitle the applicantto <br />conduct operations tbercon. <br />Conditions of approval, if any, arc attached. <br />Tide IS U.S.C. Samoa 1001 and Tnle 43 U.S.C. Section 1212, make it a crime for any person knowinpJ y and willful to make to am <br />Statesany false, fictitious or fraudulent statements or representations as to any matter within its jurisdiction y or agency of the United <br />(Continued on page 2) *(Instructions on page 2) <br />