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Furffl 3160-5 UNITED STATES <br />(Jane 1990) DEPARTMENT OF THE INTERIOR <br />BUREAU OF LAND MANAGEMENT <br />SUNDRY NuTICES AND REPuRTS uN WELLS <br />Do not ase this form for prupvsals to drill or is deepen ur reent y to a dlrm orit Faaer7vlr <br />use "APPLICATION FOR PERMIT-" ter loch proposals <br />SUBMIT IN TRIPLICATE <br />1. Type of Well <br />❑ Oil Well ❑ Gas Well O other Nacholite Solation M;rl u <br />2. Name of Operator <br />A—urivan Soda, L. L. P. <br />3. Address and Telephone No. <br />2717 County Road 215, Parachute, t,olorado 81635 <br />4. Location of Well (Footage, Sec., T., R., M., or Surrey Debmiption) <br />13,087.01 Eastiny I9W i, of NE i. of 5zictio , 29, T1 S, R97W 6" P.M. <br />12,774.16 Northing <br />12. CHECK APPROPRIATE BOX(.,) TO INDICAI E NATURE OF NUTIC;E, REPORT OR OI HER DATA <br />FORM APPROVED <br />Bu5get Bureau Mo tiUMuioa <br />Mares I6arcn 3t, iaao <br />n [ease oesignauon an'a renal Mo <br />Yarill Gal.n CO-naiza <br />6 If Indian, Allottee or Tribe Name <br />AIA <br />7 If Uni, or CA. Ayreemen, Designation <br />N/A <br />8 Well Name and No <br />Amedran Soua [ C P N-ao <br />EVA Clazz III COaaoa-u_40/6 <br />v AVI well no <br />29-29 (Nahcoljre) <br />10 Fell! an0 Pool, or Exploratory Area <br />Central Piceance Creek Basin <br />i i County or Vonan. State <br />Rio Blanco, Colvradc <br />TYPE OF SUBMISSION I TYPE OF AL; I IUM <br />0 Notice uf Intent ❑ Abandonment <br />❑ Rewiiipletiurt <br />❑ Sobauquent Reports L7Plo-yyln—y Back <br />❑ Casing Repair <br />❑ Final A5andonment Notre ❑ Altering (;asiny <br />❑ uther <br />❑ Change UT Plans <br />❑ New Construction <br />❑ Non-Ruatine Fractariny <br />❑ Water Shut-uff <br />❑ Cxnvclsion to Iniectiun <br />❑ Dispose Water <br />Note Report results in mulopre completion on Well <br />C—pid— m R.e•rnpletien R.port and Lep f- <br />13. Describe Proposed or Completed Operations (Clearly state all pertinent details, and give pertinent dates, including estimated date of <br />starting any proposed wvrk. If well is directionally drilled, give sobsoface locations and measured and true vertical depths for all markers <br />and zones pertinent to this work./= <br />• Well 29-29 dissolution surfacr at 1634'. <br />• On 8/20/2004 Rig up Kay Energy on well. Nipple down wellhEad. <br />. On 8/23/2004 Pall 2399' tall) of 41/2-' long string. Set cast iron bridge plug at 1685' on long 7" casing. Pull 2004' jail) of 4 %- ohurt otrinb. Set <br />cast iron bridge plug in /-snort string at 16a5 . Rig Down Rey Energy. <br />• both strings of well .A -c7 passed Mli i on 9/ 0/2008. 8/.7/20,0_ 5/30/2012, and 6/4/2014. <br />• On 8/XX/2015 RACS tripped coil tubing to the cast iron bridge plug at 1685' and pumped 315 sacks of Type G cement, 15.8 #/gallon, 1.15 <br />ft3/sack cement, slurry volume 362 ft3 in 3hvrt string T' ca3in6. <br />• On 8/XX/2015 RACS trippzd coil tubing to the cast iron bridge plug at 1685- and pumped 315 sacks of Type G cement, 15.8 #/gallrn, 1.15 <br />n3/sacR cement, slurry volume ioz its in lung string I" casing. <br />• wellhead is cut down and a cap is placed on the cemented casing strings indicating the date of plugging and abandonment and the well <br />identification. <br />14. 1 hereby certify that the TOM90lny is true and con uct <br />Signed <br />Title Plant Manager Date August XX, 2015 <br />(This space tur Federal or State ornce use) <br />Approved by Title <br />Cor rditlons of appr-.val, if any: <br />Date <br />Title 18 U.S.C. Section 1001, makes it a crime for any person knowingly and willfully to make to any department or agency of the United <br />States any false, fictitioas or traadolent State nents yr representations as to any matter within its iarizidiction. <br />*See Instruction an Reverse Side <br />