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1 IL LOCATION: <br />The following information is required for ALL prospecting drill holes: <br />F-4 14 of the ® 114 of Section <br />6TH PM I Prime Meridian <br />4�1 Township Range <br />OUSTER I County <br />Page 2 of 3 <br />�2w <br />If the area has not been surveyed, supply the Longitude �� West and Latitude North, <br />or a a location map, preferably a USGS Quad. <br />The following additional information is required for artesian dowing holes: <br />Feet ❑ North ❑ South from the ❑ South ❑ North section line <br />feet ❑ east ❑ West from the ❑ west ❑ East section line <br />i�OTE: <br />In the case of closely spaced drill holes having similar geologic and hydrologic characteristics, 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, completezee abandfonnx-nt 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 l or subsection 2 boxes as appropriate and provide the <br />requested information) <br />® 1. Plugged dry hole, method of plugging: d NC R ETE P L UG <br />Depth at which concrete plug set: 20 feet below ground surface. <br />® 2. Sealed Hole (when groundwater is encountered): <br />El2a. Neat Cetnent Grottt, 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 />BENTONITE: SAROID EXTRA GEL <br />