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Form Approved UMe No 2(140-0042 Approval Expires 6-30-9 <br />~ C~/~ UNITED STATES ENVIRONMEMAL PROTECTION AGENCY <br />\OEr7'\ WASHINGTON, DC 20960 <br />PLUGGING AND ABANDONMENT <br />NAME AND ADDRESS OF FACILITY <br />American Soda LLP. <br />27991 County Road 5 <br />Rifle, Co, S1FS0 NAME AND ADDRESS OFOWNER/OPERATOR <br />American Soda LLP. <br />2717 County Road 215 <br />Paradtuce, Co, 81635 <br /> <br />LOCATE WELL AND OUTLINE UNI'C ON <br />SECITON PLAT - bt0 ACRES SLATE <br /> <br />CO. COUNTY <br /> <br />Rio Blanco PERMIT NUMBER <br /> <br />C03856-04570 <br /> <br />N SURFACE LOCATION DFSCRIFTION <br />SE'/., NE Y., NE Y., Section 29, Township 15 Range 97W <br /> LOCATE WELL IN TWO DIItECT10NE FROM NEAREBT LINES OF QUARTER SECTION AND DRB.LING UMI' <br /> X Surface <br />1050' FNL 11890.16 Northing <br /> 225' FEL 1494282 Eason <br /> TYPE OF AUTHORIZATION WELL ACTIVITY <br />W E X Individual Permit <br />p Area Pemtit CLASS I <br />o CLASS Il <br /> p RWe o Brine Disposal <br />D Enhanced Recovery <br /> Number of Wells 1_ o Hydrocarbon Storage <br />Ox CLASS lII <br /> Side by Side Dual T' Casing Completion <br />S Lease Name Yankee Gulrh WeB Number 29-22 <br />CASING AND TUBING RECORD AFTER PLUGGING METHOD OF EMPLACEMENT OF CEMENT PLUGS <br />S¢E WT(LB/F1') TO BE PUT IN WELL(Fn TO BE LEFT Al WELI.IFry HOLE SIZE O The Balance Method <br />2d' S3 0 4d 24" O The dump &ai]er Method <br />T' 26 0 - 1806' 19" O The Two-Plug Method <br />T' 26 0 2043' 1'Y' X Other <br /> Call 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 Pi W which Plu Will Be Placed inches) n 7" Short) <br />r to Bouam of Tubin or Drill Pi fk 1634 1632 <br />Sacks of Cement Used each lu 239 739 <br />Slurrv Volume Pum d cu. ft) 370.5 370.5 <br />Calculated To of Plu ft Surface Surface <br />Measured To of Plu ff to ed ft) Surface Surface <br />SI Wt Lb./Gal. 15.6 15.6 <br />T cement or other macerial Class T G T G <br />LISF ALL OPEN HOLE AND/O R PERFORATED INITERVALS WHERE CASING WILL BE VARIE D (i a ) <br />From To From To <br /> <br /> <br /> <br /> <br /> <br />Pleav reference attached BLM Sundry Fom <br />CERTIFICATION <br />I certify wrier the penalty of the Ww that I have persona Ely ewmerted and am familiar with the in/onwtiart <br />submitted in this dacvmmtartd all attachments and thak based on my inquiry of tMse individuals <br />immediately rcspoasiblefor obtaining the irtformah'vn, 16elieae that the information is true, accurate, <br />acrd compote. I am aware that there are sigmfirvnt penalties for submitting false infamwHon, including <br />the pvssrbility of/irte and imprfsomneak (Itef. 40 CFR 144.32 <br />NAME AND OFFICIAL TITLE (Phase type or print) <br />Max Ramey Piceance Operadons Manager SIGNAN <br />(~.. DATE SIGNED <br />September 14, 2004 <br />EPA Form 7520-19 <br />