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Firm 31bu-5 ural I ED S 1 ATES <br />(June 1990) DEPARTMENT OF THE INTERIOR <br />BUREAD OF LAND MANAGEMENT <br />SUNDRY NOTICES AND REPORTS ON WELLS <br />Do not use this form fol pioposalb to drill or to deepen or reentry to a different reservoir <br />Use "mPPLICATION FOR PERMIT-' for such proposals <br />SUBMIT IN TRIPLIL ATE <br />1. Type of Well <br />❑ Oil Well ❑ Gas Well O Other Nacholite Solation Mining <br />2. Name of Operator <br />American Soda, L. L. P. <br />3. Address and Telephone No - <br />2717 upunty Road 215,_ Parachute, Colorado 81635 <br />4. Location OT Well (Footage, Sec., T., R., M., or Survey Description) <br />14,558.19 Eabtiny SE Y. of SE X. of Section 20, T1 S, R97W 6" P.M. <br />13,383.35 Northing <br />12. CHECK APPROPRIATE BOX(s) TO INDIuATE NATURE OF NOTIL,E, <br />TYPE OF SUBMISSION <br />ONutioe of Intent <br />❑ Subsequent Reports <br />❑ Final Abandonment Notice <br />❑ Abandonment <br />❑ Rucomplatiuri <br />O Plugging Back <br />❑ Casing Repair <br />❑ Altering easing <br />❑ Other <br />FORD rcPPRr—EV <br />Bu„ye, Bureau 170 .w w.39 <br />Exoires March 31 .993 <br />5 Lease Desynation and Sena] No <br />T anrtee uulcn CO- I Iwca <br />6 1T mman, Allonee or I rive Fame <br />N(A <br />i rr Unn or CA, Agreement oeslgnaaen <br />FIA <br />a vvel. Fame an0 Mo <br />ARI—C•n Sofia L L P 20-19 <br />.r m Class III C'vao�va <br />9. API Well No <br />LO -19 (Mancollte) <br />10 Field and Pool, or Exploramry Area <br />central Piceance (;,eek Basin <br />.. County or PansM, scale <br />Rio Blanco, Colorado <br />RT OR OTHER DATA <br />TYPE OF ACTION <br />❑ Change of Plans <br />❑ New cunstraction <br />❑ Non -Routine Fracturing <br />❑ Water Shat -Ott <br />❑ Conversion to Injection <br />❑ Dispose Water <br />(N.l. Report rr--alts in reaftipl� -0A.. ea Well <br />comilletion or Re-mmetion Report and Log form <br />13. Deacribe Propoaeo u. Curripl�tEd uperatiuris (ulEarly atatu all perti.nEnt aetaila, and yi.e pertinent dates, incluainy 'estimated date of <br />starting any proposed work If well is directionally drilled, give subsurface locations and measured and true vertical depths Tor all markers <br />al id zol les pertinent to this n,urk.)' <br />• Well 2u-19 oi..olutiari 3ul`facc at 1465'. <br />un i/24/2uu4 Rig up Key Erie.gy un ..ell aria nipple du..n ..eIlRead. <br />7/26/20u4 Poli 2204' (all) wT 4 1/2- lung String. Sat cast irum linage plug at 1515' un I ng i" using. Pell 1816' (all) ur 4 J" <br />bhorTbaring. Set CdbL iron Bridge plug at 1515' on bhurT7" Casing. Rig down Key Energy and move to next location. <br />• On 9/11/2008 Well 20-19 7" lotig btring tailed MIT. <br />• On 12/17/2008 — Halli5orton tripped Coil 1.06ing Lu Ll le Cdba iron Bridge Flag aL 1515' dna pumped 280 bdCRS of Type G cement, <br />15.8 #/gallon, 1.15 tt`/rZK ceme.,t, 3lorry .ulume 322 Tt, in 3RurtString 7- ca.ing. <br />UM 8/XX/zu15 — RAL5 t. ippea Coil tubing to trw CoA ]rum Briaga plug at 1515 aria pumped 283 SaCK. oT Type 6 cement, 15.8 <br />#/gallon. 1.15 tt'/bdLR Cement- blurry volume 325 ttl in bholT bLring 7' Cabing. <br />• WeIlFeaa ib CUL down ana a cap ib placed on LhE Cabing bLringb indicating Lhe date at plugging dna d5dnaonment and the well <br />iaentificatiori. <br />14- 1 hereby certiry that the foregoing is true and correct. <br />Signed <br />Title Plant Manager Date August XX, 2015 <br />l i his space for Federal or State office ase) <br />Approved by Title Date <br />t,onditions OT approval, if any: <br />Title 18 U.S.C. Section 1001, makes it a crime fol any person knowingly dnd wilifally to make to any department or agency of the United <br />Statea any Talse, T,ctitious or Trauaulent statements or representations as to a .y matter ..ithiri ita luribaiirtion. _ <br />-See Instruction an Reverse Side <br />