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Page 2 o£3 <br />III. LOCATION: <br />The following information is required for ALL prospecting drill holes: <br />1414 of die© 1/4 of Section Township Range 7z <br />E:75TH PM Prim1e Meridian CUSTER County <br />If the area has not been surveyed, supply the LongitudeE:7�j 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 North section line <br />feet ❑ east ❑ West from the west ❑ East section line <br />NOTE: In the case of closely spaced drill hones having similar geologic and hydrologic characteristics, the Operator may, <br />with the approval of lite Division, submit a single consolidated final report iwJuding the location of all drill holes and a <br />description of abandonment technique_ In such case, complete py 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 I or subsection 2 boxes as appropriate and provide the <br />requested information) <br />® 1. Plugged dry hole, rnetlmd of plugging: CONCRETE PLUG <br />Depth at which concrete plug set: feet below ground surface. <br />El2. 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 />Intmmils grouted (feet beneath ground surface, method and materials): <br />© 2c. Abandonment Fluid Mixture (Such as Sodium Bentonite with Polymer) Brand Name: <br />BENTONITE: BAROID <br />