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Fonn3160 -3 <br />(August 2007) <br />UNITED STATES <br />DEPARTMENT OF THE INTERIOR <br />BUREAU OF LAND MANAGEMENT <br />FORM APPROVED <br />OWNa lW"t37 <br />E*ra July 31, 2010 <br />5 Lease Serial Nor <br />C- 0118327 <br />APPLICATION FOR PERMIT TO DRILL OR REENTER I & If Indian, Allotee or Tribe Name <br />nor <br />Ia. Type of work: [Z]DRILL REEK (ER <br />7 1 Unit or CA Agreement, Name and No. <br />Natural Soda, Ina <br />lb. Type of Well: � Oil Well � Gas Well QOther Single Zoe Multiple Zone <br />S. Lease Nam and Well No. <br />171-14 <br />2 Name of Operator Natural Soda, Inc. <br />9. API Well Na <br />na <br />3n. Address 3200 Rio Btanoo County Road 31 <br />3b• Phone Na (d& urea cad) <br />10. Field and Pool, or Exploratory <br />Rifle, CO 81650 <br />(970) 878 -3674 <br />Boles Bed, Nahcolite <br />4. Location of Well (Report loeaam clearly and in arex:nbu wirh any &ate reqwvam *) <br />11. Sec., T. R ltd. or Bic and Survey or Area <br />At surface Lafflude 39.9261676% N Long tude 108.371007846 W, NAD83 <br />SHL: Sec 34, T1S, R98W, 6th P.M. <br />At proposed prod. zone <br />14. Distance in miles and direction from nearest town or post offia- <br />12. County or Parish <br />13. State <br />­0 mites southwest of Me&" Colorado <br />Rio Bianco <br />CO <br />15. location from om proposed* 394 ft. <br />382 6of acres in lease <br />17. Spacing Unit dedicated m this well <br />roperty or lease Iirre, ft. <br />A}so to nearest dug. unit line, if any) <br />I& DisW" from �d location* 77 ft. <br />to drilling, <br />19. Proposed Depth <br />20. BLMMA Bond Na on file <br />nearest well, completed, <br />applied for, on this lease, h . <br />-• g675 ft MD <br />—1844 fLTVD <br />21. Elevations (Show whetherDF, KDR RT, GL, etc.) <br />22 Approximuft date work will start* <br />23: Estimated duration <br />GL <br />0912812015 <br />35 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 form <br />1. Well plat certified by a registered surveyor. <br />2 A Dulling Plan. <br />3. A Surface Use Plan (if the location is on National Forest System Lands, the <br />SUPO must be filed with the appropriate Forest Service Office). <br />4 Bond to cover the operations unless covered by an existing bond on file (see <br />Item 20 abovc} <br />5. Operator certification <br />6. Such other site specific information and/or plans as may be required by the <br />25. Signature - Name (Fri9edT)p4 <br />Gerald Daub <br />Tide ' <br />President, Daub & Associates, Inc. <br />Approved by (Soovej Name (PrimedtTMxd) Date <br />Title I Office <br />Application approval does riot warmat or certify that the applicant holds legal or equitable tide loo those rights in the subjectleasewhich would emidethe applicant to <br />conduct operations thereon. <br />Conditions of approval, if any, are attached. <br />Title 3 USG Section 1001 and Tide 43 U.S.C. Section 1212, make it a cAne for any person ktwwi and willfully to make to any department or agency of the United <br />States any false, fictitious or fraudulent statements or representations as to any matter within its jurisdiction. <br />(Continued on page 2) *(Instructions on page 2) <br />