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Form Approved UMB No 2040-0042 Approval Expires 53(49 <br />~yG~ UNITED SCATES EW IRONMEMAL PROTECTION AGENCY <br />W ASFBNGTON, DC 20460 <br />PLUGGING AND ABANDONMENT <br />NAMF_ AND ADDRESS OF FACILITY <br />American Soda L.LP. <br />27991 County Roa4 5 <br />Rifle, Co, 81650 NAME AND ADDRESS OF OWNER/OPERATOR <br />American Soda LLP. 'i <br />2717 County Road 215 ' <br />Parachute, Co, 81635 <br /> <br />LOCATE WELL AND OUTLINE UNR ON <br />STCITON PLAT -690 ACRES SCATS <br /> <br />CO. COUNTY <br /> <br />Rio Blanco PERMIT NUMBER <br /> <br />CO365R-04561 <br /> <br />N SURFACE LOCATION DESCRIPCION <br />SW Y., SE Y., SW Y., Section 20, Township 1S Range 97W <br /> I.O(ATE WELL PI TWO DBiEC110N5 FROM NEAREST LPIFS OF QUARTER SECTION AND DR-.I1NG IfNR <br /> Surface <br />5110' FSL 13206.87 Northing <br /> 1554 FWL 11559.51 Eastin <br /> TYPE OF AUTHORIZATION WELL ACI'IV1TY <br />W E X Individual Permit <br />0 Area Permit CLASS I <br />0 CLASS II <br /> o RWe o Brine Disposal <br />p Entranced Recovery <br /> Number of WeLLs _1_ p Hydrocarbon Storage <br />O CLASS III <br /> X Side by Side Dual T' Casing Completion <br />S Leau Name Yankee Gulch WeB Number 20.35 <br />CASING AND TUBING RECORD AFTER PLUGGING METHOD OF EMPLACEMENT OF CEMEM PLUGS <br />BCLE WT(LB/F'O TO BE PITT IlV W ELL(FT) TO BE LEFT EV WELUE'O HOLE SIZE O The Balance Method <br />20" 53 0 8d 24" O The dump Bailer Method <br />r' 26 0 195T 19" D The Two-Plug Mehod <br />r' w o 2z92' 19" x omer <br /> Coil Tubing Unit <br />CEMENTING TO PLUG AND ABANDONED DATA PLUG #1 PLUG #2 PLUG #3 PLUG #4 PLUG #5 PLUG #6 PLUG #7 <br />Size of Hole or R m which Plu Will 8e Placed inches 7" T' Short <br />D to Bottum of Tulrin or Drill Pi ft 1790 1740 <br />Sacks of Cement Used each lu 267 249 <br />SI Volume Pum d cu. (t 413.9 385.9 <br />Calculated T of Plu ft Surface Surface <br />Measnrred To of Plu fl m ed It Surface Surfarn <br />SI Wt. b./GaI. 15.6 15.6 <br />T cement or other material Clan I T C T G <br />LIST ALL OPEN HOLE AND/O R PERFORATED INTERVALS WFTERE CASING WI LL BE V ARIE D (i a ) <br />From To From To <br /> <br /> <br /> <br /> <br /> <br />Please reference attached BLM Sundry Form. <br />CERTIFICATION <br />I rert/y under the pew(!y of the Ecru that I Mae persowlly eramkred arut am familiar unth the information i <br />submitted in this document and a(( attachmtnts and that, baud on my inquiry of thou indiaidua(s <br />immediare(y rcsponsib(<for obtaining the information, 1 belime that the information is true, accurate, <br />and romp4tt. I am amore that there are significant penalties for submitting falu information, including ' <br />the possibility of fine and impnsonmtnG (Ref. 40 CFR 144.32 <br />NAME AND OFFICIAL TTCLE (Please type orpnnt) <br />Max Ramey Pireance Operadore Manager SIGNATURE DATE SIGNED <br />September 14, 2004 <br />EPA Form 7521414 <br />