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Page 2 of 3 <br /> 7NE1/4 of the FN Ej 1/4 of Section 21 Township 45N Range 8W <br /> NMPM I Principal Meridian San Miguel---] County <br /> If the area has not been surveyed, supply the Longitude 108.853573 West and Latitude 38.144010 North, <br /> or attach a location map,preferably a USGS Quad. <br /> The following additional information is required for artesian flowing holes: <br /> N/A Feet ❑ North ❑ South from the n <br /> South ❑ North section line <br /> N/A feet 1-1 <br /> east ❑ West from the R <br /> west P 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 /> 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 ABA DONMENT (Check either box 1 or subsection 2 boxes as appropriate and provide the <br /> requested information) <br /> IY I 1. Plugged dry hole, method of plugging: Ibaekfill hole with cuttings. if drilled wet, pump sump <br /> Depth at which coacrctc plug set: N/A feet bclew gi-ound surface. <br /> 11-711 2. Sealed Hole(when groundwater is encountered): <br /> rl2a. Neat Cement Grout,top to bottom: grout mixture used: <br /> N/A <br /> Intervals grouted(feet beneath ground surface, method and materials): <br /> N/A <br /> n <br /> 2b. Neat Cement Grout. interval grouting: grout mixture used: <br /> N/A <br /> Intervals grouted(feet beneath ground surface, method and materials): <br /> N/A <br /> 13 2c. Abandonment Fluid Mixture(Such as Sodium Bentontte with Polymer)Brand Name: <br /> N/A <br /> Marsh Funnel viscosity of abandonment fluid: sec. <br />