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Page 2 of 3 <br /> HL LOCATION: <br /> The following information is required for ALL prospecting drill holes: <br /> �r1/4 of the ® 1/4 of Section � Township r-,� Range 72w <br /> 6TH PM Prime Meridian CUSTER 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. <br /> The following additional information is required for artesian flowing holes: <br /> Feet ❑ North South from the ❑ South a North section line <br /> feet L� east ❑ West from the ❑ west ❑ East section line <br /> NOTE: In the case of closely spaced dril 11 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: CONCRETE PLUG <br /> Depth at which concrete plug set: 20 feet below ground surface. <br /> ® 2. Sealed Hole(when groundwater is encountered): <br /> El2a.Neat Cement Grout,top to bottom: grout mixture used: <br /> Intervals grouted(feet beneath ground surface,method and materials): <br /> ® 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 /> BENTONITE: BAROID EXTRA GEL <br />