2016-04-15_HYDROLOGY - M1999051

• Permit No: M1999051
• IBM Index Class Name: Hydrology
• Doc Date: 4/15/2016
• Doc Name: Submission of Information Requested for Monitoring Well
• From: Daub & Associates
• To: DRMS
• Email Name: THM
• Media Type: D
• Archive: No

August 0
( TED STATES
Aug22000 7) UNITED
FORM APPROVED
OF THE INTERIOR
OMR No. 1004-0137
BUREAU OF LAND MANAGEMENT
Expires: July 31, 2010
S. Lease Serial No.
SUNDRY NOTICES AND REPORTS ON WELLS
C-0118326
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 3960-3 (APD) for such proposals.
SUBMIT IN TRIPLICATE — Other instructions on page 2.
7. If Unit of CA/Agreement. Name and/or No.
Natural Soda LLC
I. Type of Well
❑ Oil Well ❑ Gas Well m Other
8. Well Name and No.
15H-SSMW
2.Name of Operator
N
Natural Soda LLC
9. API Well No.
3a. Address
3200 Rio Blanco County Road 31
36. Phone No. (include area code)
10. Field and Pool or Exploratory Area
Rifie, co 81650
[phone]
4. Location of Well (Foots e. Sec., T,R.,M.. or Survey Description)
39.927270 N, 108 367950 W, NA� B3, Sec. 26, T. IS, R 98W
1 I. Country or Parish, State
Rio Blanco, CO
12. CHECK THE APPROPRIATE BOX(ES) TO INDICATE NATURE OF NOTICE, REPORT OR 01•11ER DATA
TYPE OF SUBMISSION TYPE OF ACTION
❑Notice of Intent ❑ Acidize ❑ Deepen ❑ Production Start/Resume
(, ) ❑Water Shut -Off
❑ Alter Casing ❑ Fracture I neat ❑ Reclamation ❑ Well Integrity
© Subsequent Report ❑ Casing Repair ❑ New Construction ❑ Recompletc Other Change Location
❑ Change Plans ❑ Plug and Abandon ❑ Temporarily Abandon
❑ Final Abandonment Notice ❑ Convert 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 work will be performed or provide the Bond No. on file with BLM/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 recompletion in anew 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.)
In accordance with BLM conditions of approval (Item 9) reference number LLCON0503592 the surface hole location of the NS 15H-SSMW has been changed
as shown above. Included with this sundry notice are the survey plat for the drilling location, construction layout diagrams, cut and fill diagrams, and drilling
plan/prognosis.
14. 1 hereby certify that the foregoing is true and correct.
Name (11rinred,7} ped)
Gerald J. Daub Title President, Daub & Associates, Inc.
Date y_ Z _ 14
THIS SPACE FOR FEDERAL OR STATE OFFICE USE
Approved by
Conditions of approval, 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
(Instructions on page 2)