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Page 2 of 3 <br /> DLO <br /> 1II.LOCATION: <br /> The following information is required for ALL prospecting drill holes: <br /> 1-N-7q 1/4 of the 1/4 of Section Township Range <br /> {� L-A ,l !` Prime Meridian � 5.. County <br /> If the area has not been surveyed,supply the Longitude West and Latitude North, <br /> or attach a location map,preferably a USGS Quad. 1I <br /> The following additional information is required for artesian flowing holes: <br /> Feet North South from the ❑ South ❑ North section line <br /> feet ❑ east ❑ West from the ❑ west East section line <br /> NOTE: In the case of closely spaced drill holes having similar geologic and hydrologic characteristics,the Operator may, <br /> with the approval of the Division,submit a single consolidated final report including the location of all drill holes and a <br /> description of abandonment technique. In such case,complete one abandonment final report form and attach a list of drill <br /> hole locations. If more space is needed to provide any of the information for this form,please attach separate sheets. <br /> IV. Complete Either Subsection A or B: <br /> PERMANENT ABANDONMENT (Check either box 1 or subsection 2 boxes as appropriate and provide the <br /> requested information) <br /> © 1. Plugged dry hole,method of plugging: <br /> Depth at which concrete plug set: feet below ground surface. <br /> ® 2. Sealed Hole(when groundwater isencountered): <br /> 2a.Neat Cement Grout,top to bottom: grout mixture used: <br /> Intervals grouted(feet beneath ground surface,method and materials): <br /> 0 - ; ri/ <br /> 0 2b.Neat Cement Grout,interval grouting: grout mixture used: <br /> Intervals grouted(feet beneath ground surface,method and materials): <br /> 2c. Abandonment Fluid Mixture(Such as Sodium Bentonite with Polymer)Brand Name: <br />