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. .. , <br />Form Approved UMB No 20409042 Approval Expires 630.9 <br />`S ~~ UNITED STATEi ENVIRONMENTAL PROTECTION AGENCY <br />wnsT~rcroN, rx 20460 <br />PLUGGING AND ABANDONMENT <br />NAME AND ADORES OF FAC[LT1Y <br />American Soda LLP. <br />27991 County Road 5 <br />AiBe, Co 81650 NAME AND ADDRf~ OF OWNER/OPERAI[Ht <br />Avasican Soda LI.P. <br />2717 Counl Road 215 <br />Parachute, Co, 81635 <br /> <br />LOCATE WELL AND OUTLINE UNIT ON <br />SECTION PLAT -640 ACRES SPATE <br /> <br />CO. ODUFIfY <br /> <br />Rio Blanm PFZIMIT NUMBER <br /> <br />00385804.571 <br /> <br />1~ SURFACE ioCAT[ON DFS(RIPI'ION <br />FIE Vs, NE Y., SecBOn 29, Township ]S Range 97W <br /> X <br />I.IXAlE WELL IN1W0 DIXECTpFS FROM NFARESC III4F5OF QUARTER SP.CTION AND DRII.2ING UNR <br /> Surface <br />577 FNL 1234057 Northing <br /> 497' FEL 24613.93 <br /> TYPE OF AUTHORIZATION WELT. A('TIVTIY <br />W E X Individual Permit <br />p Area Panut CLASS I <br />o CI.A.%ll <br /> o Rule o Brine Disposal <br />p Enlanced Rxrn'erY <br /> Number of Wells _I_ o HYdr~~n <br />O CLASS IE <br /> Side by Side Dual T Casing Completion <br />$ Lease Name Yankee Gulch Well Nuudrer 29.23 <br />CASING AND TUBING RLl70RD AFTER PLUGGING MEl'I IOD OF IIdPI.ACCE EMEN'1' OF CEMENT PLUGS <br />SL7E wrfLR/Fl) IO BE PITT PI WF~.I{FT) 1'O 10?IEFTIN WELI(F l) 1i01.B5@ O TLe Balance Metllod <br />24" 95 0 Sd 30" D The dump Bails Metlnd <br />T 26 0 1&63' 19" ~ The Two-Aug Method <br />T w o n7n' 19" X outer <br /> Coll Tutring Urdt <br />CEM I7417NG TO PLUG AND ABANDONED DATA PLUG Kl PLUG 42 PLUG •3 PLUG it4 PLUG 45 PLUG 716 PLUG 717 <br />Siae of Hole or Pi in which A WID >ie Plated ira#tes T T <br />>b eoltomaT or Drill Et 1615 1610 <br />SacksaC~uuent Used each lu 37B 328 <br />s vaame a,. tt. a36.o 434a <br />CakvlatedT ofR ft SurGce Surface <br />Measured To ofPl dm R Surface Surfam <br />51 Wt ./GaL 15b i5b <br />7 cea~tor oNmr material Class T G T G <br />LISP ALL OPEN HOLE AND OR PFRFORAT FT) INTERV ALS WftFRE CASING WI LL FfE VARIE D ( ) <br />From To Front To <br /> <br /> <br /> <br /> <br /> <br />Please reference attached BLM Sundry Form. <br />CERTIFICATION <br />I certify cruder dre ptwlty of the lam that t han persoaaliy caarnirttd and am familiar roith the irtfomution <br />submitted in Kris document and dl attachments and Nuk 6aard on my vigairy of those indfoidaa4 <br />immediately rcaportstb4 jor obtaining the infarmatloq I brlierr that tlrc fnformafion is frae, accurate, <br />and toarp4fe.7au auarc Nut ttrrcarc sigrdfiront pnmltlas jorsabmlttingfalse irr/onnatuat intlading <br />tlm posstbflity of fiat sad imprisotmtent. (Ref. 40 flR 14432 <br />NAME AND OFFICIAL TITLE (P4au type orprvd) <br />Iid Cooley Envvonnrntal CotsWtam SIGNATURE DATE SIGNED <br />November 12, 20116 <br />EPA Form7520-14 <br />