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Page 2 of 3 <br />11L LOCATION: <br />The following inforrriation is required for ALL prospecting drill holes: <br />E:�,.114 of the ®114 of Section Township Range 7 �w <br />6TH PM €'rime Meridian CUSTER I County <br />If the area has not been surveyed, supply the longitude West and Latitude North, <br />or h a location map, preferably a USGS Quad. <br />The following additional information is required for artesian flowing holes: <br />Feet �J North ❑ South from the ❑ South ❑ North section kine <br />feet ❑ east ❑ West from the west ❑ East section line <br />NP TE: In the case of closely spaced drill holes having similar geologic and hydrologic characteristics, the Opmator nmy, <br />with the approval of the Division, submit a single consolidated final report including the kxation 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 />W. Complete Either Subsection A or W. <br />PERMANENT ABANDONMENT (Check either box 1 or subsection 2 boxes as appropriate and provide the <br />requested information) <br />U1. Plugged dry hole, method of plugging: L CONCRETE PLUG <br />Depth at which concrete plug set: =feet below ground surface. <br />El2. Sealed Hole (when groundwater is encountered): <br />n2a. Neat Cement Grout, top to bottom: gout mixture used: <br />E _ <br />- . . I <br />Intervals grouted (feet beneath ground surface, method and materials): <br />® 2b. Neat Cement Grout, interval Muting_ grout mixture used: <br />Intervals grouted (feet beneath ground surface, method and materials): <br />11 2c. Abandonment Fluid Mixture (Such as Sodium Bentonite with Polymer) Brand Name: <br />BENTONITE: BAROID EXTRA GEL <br />