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]ULLOCATION: <br />The following information is required for ALL prospecting drill holes: <br />A of the ® 114 of Section <br />6TH PM P meme"an <br />Township Range <br />CUSTER County <br />Page 2 of 3 <br />72W <br />If the area has not been surveyed, supply the Longitude West and Latitude Noah, <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 ❑ west ❑ East section line <br />NOTE: In the case of etmely spared drill }toles having similar geologic and hydrologic &a�tirs, the Operator may, <br />with the approval of tbe Division, submit a single consolidated final report including the location of atl drill holes and a <br />description of abandonment technique. In such case, complete ort abandonment final report form and attach a list of drill <br />hole locations. If more space is needed to provide any of the inforau lion for this form, please attach separate sheets. <br />tv. Complete Either Subsection A or B; <br />PERMANENT ABANDONMENT (Check either box I or subsection 2 boxes as appropriate and provide the <br />requested irtfosmation) <br />® 1. Plugged dry hole, method of plugging: CONCRETE PLUG <br />Depth at which concrete plug set: 2❑ feet below ground surface. <br />El2. Sealed Note (when groundwater is encountered): <br />2a- Neat Cement Grout, top to bottom: grout mixture used: <br />Intervals grouted (feet beneath ground surface, mediad 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: EXTRA GEL <br />