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<br /> <br />Form 3160-5 UNITED STA'T'ES <br />(September 2001) DEPARTMENT OF THE INTERIOR <br />BUREAU OF LAND MANAGEMENT <br />SUNDRY NOTICES AND REPORTS ON WELLS <br />Do not use this form for proposals to dri!! or to re-enter an abandoned we!!. <br />Use Form 3160 - 3 (APD) for such proposals, <br />code) 970-878-3674 <br />EPA permit C03358-00696 <br />SUBMIT IN TRIPLICATE-Other instructions on reverse side. <br />1. <br />of <br />Oil Well Gas Well Other XX <br />Monitoring well <br />3a. 3200 County Road 31, Rifle Colorado 81650 <br />3. Location of Well (Footage, Sec., T., R., M., or <br />1757'FWL 562 FSL SEC 26 T1S R98W <br />20 FEET NORTH OF 2M-TDR <br />TYPE OF SUBMISSION <br />^ Notice of Intent <br />® Subsequent Report <br />^ Final Abandonment <br />Notice <br />TYPE OF ACTION <br />^Acidize ^Deepen ^Production ^Water Shut-Off <br />^ Alter Casing ^ Fracture Treat (Start/Resume) ^Well Integrity <br />^ Casing Repair ^ New Construction ^Redamatlon ®Other <br />^ Change Plans ^ Plug and Abandon ^Re-complete c/o cement / IoQ <br />^ Convert to ^Temporarily Abandon <br />Injection ^ Water Disposal <br />13. Describe Proposed or Completed Operation (clearly state all pertinent details, including estimated starting date of any proposed work and approximate <br />duration thereof. If the proposal is to deepen directionally or re-complete horizontally, give subsurface locations and measured and true vertical depths of a0 <br />pertinent markers and zones. Attach the Bond under which the work will be performed or provide the Bond No. on file with BLM/BIA. Required subsequent <br />reports shall be filed within 30 days following completion of [he involved operations. If the operation results in a multiple completion or re-completion in a new <br />interval, a Form 3160 shall be filed once testing has been completed. Final Abandonment Notices shall be filed only after all requirements, including <br />reclamation, have been completed, and the opesacor has determined that the site is ready for final inspection.) <br />Ran sand bailer [0 1813 depth. Cleaned cement out of well bore. Logged to 1814 ft depth. <br />l4. I hereby certify [hat the foregoing is [rue and correct <br />Name (Printed/Typed): Rodnev A. Storev Title: WELL FIELD <br />Signature: <br />N', <br />THIS SPACE FOR FEDERAL OR STATE OFFICE USE <br />Approved by: <br />Title: <br />Conditions of approval, if any, are attached. Approval of this nofice does not warranf or <br />certify that the applicant holds legal or equitable title to those rights in the subject lease <br />which would entitle the applicant to conduct operations thereon. <br />Date: <br />Title 1S U.S.C. Section 1001 and Title 43 V.S.C. Section 1212, make it a crime for any person knowingly and willfully to make to any <br />department or agency of the United States any false, fictitious or fraudulent statements or representations as to any matter within its <br />jurisdiction. <br />(Instructions on page D <br />Alea <br />FORM APPROVED OM B No. 1004-0135 <br />Expires: January 31, 2004 <br />5. Lease Serial No. <br />Sodium lease C-0118327 <br />6. If Indian, Allottee or Tribe Name <br />7. If Unit or CA/Agreement, Name <br />and/or No. <br />Natural Soda, Inc. <br />8. Well Name and NO. <br />3M-TDR monitoring well <br />Y. <br />Description) Area <br />or <br />11. County or Parish, State <br />Rio Blanco .Colorado <br />Office: <br />