2015-08-14_HYDROLOGY - M1983194

• Permit No: M1983194
• IBM Index Class Name: HYDROLOGY
• Doc Date: 8/14/2015
• Doc Name: Notice of Intent to Plug & Abandon
• From: Daub & Assoc.
• To: DRMS
• Email Name: THM
• Media Type: D
• Archive: No

Form 3160-5 UNITED STATES
FORM APPROVED
(August 2007)
DEPARTMENT OF THE INTERIOR
04-0137
OMB pines: July 31 2010
BUREAU OF LAND MANAGEMENT
5. Lease Serial No -
o.C-0119986
C -01 19986
SUNDRY NOTICES AND REPORTS ON WELLS
6. If Indian, Allottee or Tribe Name
Do not use this form for proposals to drill or to re-enter an
abandoned well. Use Form 3160-3 (APD) for such proposals.
SUBMIT W TRIPLICATE — Other instructions on page 2.
7. If Unit of CA/Agreement. Name and/or No.
Natural Soda, LLC
1. Type of well
El WellWell8.
Oil ❑ Gas Well m Other Monitoring Well
Well Name and No.
MMC -IRI -3
2. Name of Operator
Natural Soda, LLC
9. API Well No.
n/a
3a. Address
3200 Rio Blanco County Road 31
3b. Phone No. (include area code/
10. Field and Pool or Exploratory Area
Rifle, CO 81650
[phone]
4. Location of Well (Footage, Sec.. T, R., Al., or Survey Description)
233605.62 6, N, 1194103 99 ft. E (0501. NAD 27). NWNE. S27, TIS, R98W, 61h PM
11. Country or Parish. State
Rio Blanco County, Colorado
12. CHECK THE APPROPRIATE BOX(ES) TO INDICATE NAI t1RE OF NOTICE, REPORT OR OTHER DATA
TYPE OF SUBMISSION I TYPE OF ACTION
© Notice of Intent ❑ Acidize ❑ Deepen ❑ Production (Start/Resume
❑ WaterShut-Off
❑ Alter Casing ❑ Fracture Treat ❑ Reclamation ❑ Well Integrity
❑ Subsequent Report ❑ Casing Repair ❑ New Construction ❑ Recomplete ❑ Other
❑ Change Plans m Plug and Abandon ❑ Temporarily Abandon
❑ Final Abandonment Notice ❑ ('onvert to Injection ❑ Plug Back ❑ Water Disposal
13. Describe Proposed or Completed Operation: Clearly state all pertinent details, including estimated starting date of any proposed work and approximate duration thereof. If
the proposal is to deepen directionally or recomplete horizontally, give subsurface locations and measured and true vertical depths of all pertinent markers and zones.
Attach the Bond under which the wont will be performed or provide the Bond No. on file with BI.M/BIA Required subsequent reports must be filed within 30 days
following completion of the involved operations. If the operation results in a multiple completion or rec:ompletion in a new interval, a Form 3160-4 must be filed once
testing has been completed. Final Abandonment Notices must be filed only after all requirements, including reclamation, have been completed and the operator has
determined that the site is ready for final inspection.)
Remove all existing monitoring equipment from well. Run in the well to approximately 780', circulate and clean the hole out. Cement to surface. For
additional detail please refer to the attached Drilling and Well Completion Diagram.
14. 1 hereby certify that the foregoing is true and correct.
Name (Printed'Trped)
Gerald J. Daub Title President, Daub & Associates, Inc.
Date G + l 2 /'5 -
THIS SPACE FOR FEDERAL OR STATE OFFICE USE
Approved
Conditions of appru%a], if any, are attached. Approval of this notice does not warrant or certify
that the applicant holds legal or equitable title to those rights in the subject lease which would Office
entitle the applicant to conduct operations thereon.
Title 18 U.S.C. Section 1001 and Title 43 U.S.C. Section 1212, make it a crime for any person knowingly and willfully to make to any department or agency of the United States any false,
fictitious or fraudulent statements or representations as to any matter within its jurisdiction
nstructions on page 2)