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Page 2 of 3 <br />UL L DCATION: <br />The following information is required for ALL prospecting drill holes: <br />A of the © 114 of Section Township Range 72 <br />��� Meridian C USTE R I County <br />If the area has not been surveyed, supply the Longitude West a l Latitude North, <br />or attach a location snap, preferably a U SGS Quad. <br />The following additional information is required for artesian flowing holes: <br />Feet ❑ North ❑ South from the ❑ South ❑ North section tine <br />feet ❑ east ❑ West from the ❑ west ❑ East section line <br />NOTE: In the case of closely spaced drill holes having similar geologic and hydrolog, the cvcrater rosy, <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 gW abandonment final report form acid 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 B: <br />PERMANENT ABANDONMENT (Check either box i or subsection 2 boxes as appropriate and provide the <br />requested information) <br />® 1. Plugged dry ]tole, method of plugging: CONCRETE PLUG <br />Depth at which concrete plug set: L�6 fee <br />t below ground surface. <br />El2. Sealed Hole (when groundwater is encountered): <br />© ?.a. 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 Mixnue (Such as Sodium Bentonite with Polymer) Brand Name: <br />BENTONITE: BAROID EXTRA GEL <br />