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Page 2 of 3 <br />n1L LOCATIONy: <br />The following information is required for ALL prospecting drill <br />holes - <br />14 of the ®114 of Section � Township Range 72� <br />6TH PM Prime Meridian CUSTER I County <br />If the area has not been surveyed, supply the Longitude I== 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 U west ❑ East section line <br />NUTI;_ In the caw of Closely spaced drill holes haying similar geologic and hydrologi the nay, <br />with the approval of the Division, submit a single consolidated fuel report including the location of all drill holes and a <br />description of abandonment technique. In such case, compkte orae abandonment final report farm 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 l or subsection 2 boxes as appropriate and provide the <br />requested information) <br />® 1. Plugged dry hole, method of plugging: CONCRETE PL UG <br />Depth at which concrete plug set: feet below ground surface. <br />El <br />2. Sealed Hole (when groundwater is encountered). <br />El <br />2a- 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 />BENTgNITE: BA <br />