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Form 3160-5 UNITED STATES <br />tJune 1990/ DEPARTMENT OF THE INTERIOR <br />BUREAU OF LAND MANAGEMENT <br />SUNDRY NOTICES AND REPURTS UN WELLS <br />Do i tot use this form for propusals to drill o, to deepen or ret it, y to a different asarvoir <br />Use "APPLICATION FOR PERMIT-" for Bach pi opusals <br />SUBMIT IN TRIPLICATE <br />FORM APPROVED <br />6aoyotEi"—one, i0021-ii5 <br />E;�P;res FIarM ji, taai <br />o [ease oesignauon acro banal Mo <br />Yankee Gulch CO -118328 <br />6 If Indian Xlouee or Tribe Name <br />MIA <br />7 If Unit or Cm Aggreemen, Designation <br />1. 1 ype OT Well 8 Well Name and No <br />❑ Oil well ❑ Gas Wcll O Other Nachulite Solution Mining American bo0a [ L P A-36 <br />EPA Cia„ III COaaotw4bbZ <br />2. Name of Operator y API well Mo <br />American soda, L. L. P. 20-36 (Nahcolite) <br />3. Adot css and Telaphui to No. 10 Fi810 arta Pool, or Exploratory Area <br />2717 Country Road 215_ Parachute, Colorado 81635 Ventral Piceance C;reeR Basin <br />z;. Location of Well (Footage, Sec., T., R., M., or Survey Descriptio) i) 11 County or Pansh State <br />11,197.43 Easting 5W Y, of SW 7, aT Section 20, T1 S, R97W 6i^ P. M. Ric Blanc, Ocicrado <br />13,704.50 Northing <br />IINotice or Intent <br />❑ Sa6seycent Reports <br />❑ Final Abandonment Notice <br />❑ A6andunment <br />❑ Recompletion <br />OPluyginy Back <br />❑ leasing Repair <br />❑ Altering Casiny <br />❑ other <br />TYPE OF AGTIUN <br />❑ Chango of clans <br />❑ New Construction <br />❑ No,i-Raatine Fracturing <br />❑ Water phut -un <br />❑ Conversion to It ijection <br />❑ Diapuso Water <br />jNote Report results in multiple completion on Well <br />C—pl.g.n e. R«mnpletion Ropon &A Log for <br />13. Describe Proposed or Completed Operations (Clearly state all pertinent details, and give pertinent dates, including estimated date of <br />btarting any proposed work. If well is directionally drilled, give subsurface locations and measord and true vertical depths for all markers <br />and zones pertinent to this work j' <br />• Well 20-36 di33olcidon Surface at 1721'. <br />• On 8/31/2004 Rig up Key Energy on well. Pall 2537' jall) of 4 1/2" lunb String. Set za3t iron bridgE plug at 1785' on long T' casing. <br />On 9/1/2004 Cut 4 %` short string at 1800'. Pull 1800' of 4 Y:' short string. Set cast iron bridge plug in 7' short String at 1785. Rib down Ke, <br />Energy and move to next location. <br />• 6oth mrings of well zo-36 passed ICII I on 7/10/Aua_ a/A/coi0, 3/30/colt., and 6/u/zoiu. <br />• On 8/XX/2015 RACS tripped CUil tubing to the cab. iron bridge plug at 1785' and pumped 333 3ack3 of Type G cement, 15.8 #/gallon, x.15 <br />ft3/Sack cement, 31arry vvlamc 384 ft3 in Short String T' ca.ing. <br />• On 8/XX/2015 RACS tripped coil tubina to the ca3t iron brid fie plus at 1785' and pumped 333 Sacks of Type G cement, 15.8 #/6allun, 1.15 <br />ft3/sack cement, slurry voiume 384 ft3 in long string r' casing. <br />. welill is cut clown ane a cap is placed on the cemented ca3ing strings indicating the date of plugging ane aoanoonment ano the well <br />identification. <br />14. 1 hereby Certify that the foreumnrg is true and correct. <br />Signed <br />Title Plant Manager Date August XX, 2015 <br />(This spaCE Tor Federal or State orrice use) <br />Approved by Title Date <br />Cundifiuns of approval. IT any. <br />Title 18 U.S.C. Section 1001, makes it a crime for any person knowingly and willfully to make to airy department or agency of the United <br />States any Talse, fictitioos or fraudulent stateme 43 o t epresentations as to any matter within its jurisalction. <br />•See Instruction on Reverse Side <br />