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Page 2 o£3 <br />ISL LOCATIION: <br />The following information is required for ALL prospecting drill holes: <br />14 of the 114 of Section � Township itange <br />6TH PM Prime Meridian OUSTER County <br />If the area has not been surveyed, supply the Longitude West and Latitude North, <br />or attach a location map, preferably a LISGS Quad. <br />The following additional inforrnation is required for artesian flowing holes: <br />Feet ❑ North ❑ South from the Ll South ❑ North section line <br />feet ❑ east ❑ West from the: ❑ west ❑ East section litre <br />NdTE: In the case of closely spaced drill holes having similar geologic and hydrologicteristics, 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 ooW 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 fora; please attach separate sheets. <br />IV. Complete Either Subsection A or B. <br />PERALkNENT ABANDONMENT (Check either box I or subsection 2 boxes as appropriate and provide the <br />requested information) <br />® I _ Plugged dry hole, method of plugging: C O NCR ET E PLUG <br />Depth at which concrete plug set_ �q feet below ground surface. <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: u �` <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: BA <br />