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Page 2 of 3 <br /> IIL LOCATION• <br /> The following information is required for ALL prospecting drill holes: <br /> 1119 1/4 of the 1/4 of Section 7 Township 22S Range 72W <br /> 6TH Prime Meridian CUSTER County <br /> If the area has not been surveyed,supply the Longitude 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 n South from the ❑ South ❑ North section line <br /> feet ❑ east ❑ West from the west ❑ East section line <br /> NOTE: 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,complete one abandonment final report form and attach a list of drill <br /> PERMANENT ABANDONMENT (Check either box 1 or subsection 2 boxes as appropriate and provide the <br /> requested information) <br /> 1. Plugged dry hole,method of plugging: SING DRILL PIPE, A B E N TO N ITE WAS PLACED I <br /> HOLE <br /> Depth at which concrete plug set: 20 feet below ground surface. <br /> ® 2. Sealed Hole(when groundwater is encountered): <br /> n2a.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 /> [E] 2c. Abandonment Fluid Mixture(Such as Sodium Bentonite with Polymer)Brand Name: <br />