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Form 3160-5 UNITED STATES <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 drill or to re-enter an abandoned well. <br />Use Form 3160 - 3 (APD) for such proposals. <br />SUBMIT IN TRIPLICATE-Other instructions on reverse side. <br />1. Type of Well <br />Oil Well ? Gas Well ? Other X <br />2. Name of Operator NA <br />INC <br />Address <br />3a. 3200 County Road 31, Rifle Colorado 81650 <br />3. Location of Well <br />TV PF. OF Si TBMISSION <br />? Notice of Intent <br />X Subsequent Report <br />e, Sec., T., R., M., or Survey <br />TE BOX(ES) TO INDII <br />[] Acidize <br />[] Alter Casing <br />0 Casing Repair <br />[] Change Mans <br />? Convert to Injection <br />[] Final Abandonment Notice <br />TE <br />TYPE OF ACTION <br />[] Deepen <br />[] Fracture Treat <br />[] New Construction <br />X Plug and Abandon <br />FORM APPROVED OM B No. 1004-0135 <br />Expires: August 31, 1985 <br />5. Lease Serial No. <br />Sodium lease C-0118327 <br />6. If Indian, Allottee or Tribe Name <br />EPA permit UIC C030358-00000 <br />7. If Unit or CA/Agreement, Name and/or <br />No: Natural Soda, Inc. <br />8. Well Name and No. <br />4A-4V <br />9. API Well No. <br />10. Field and Pool, or Exploratory Area <br />Boies-Bed / saline zone <br />11. County or Parish, State <br />Rio Blanco, Colorado <br />F, OR OTHER DATA <br />14. I hereby certify that the foregoing is true and correct <br />QProduction (Start/Resume) <br />[]Reclamation <br />[]Re-complete <br />[]Temporarily Abandon <br />[]Water Disposal <br />UWater Shut-Off <br />[]Well Integrity <br />[]Other <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 all <br />pertinent markers and zones. Attach the Bond under which the work will be performed or provide the Bond No. on file with BLMBIA Required subsequent <br />reports shall be filed within 30 days following completion of the involved operations. H the operation results in a multiple completion or re-completion in anew <br />interval, a Form 31604 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 operator has determined that the site is ready for final inspection) <br />Well 4A-4V was plugged and abandoned July 22, 2008. A description is attached to this Sundry notice. The Final Abandonment Notice will be submitted after <br />final reclamation. <br />Name (Printed/Typed): <br />Simature: <br />Approved by: <br />Conditions of approval, if any, are attached Approval of this notice does not warrant 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 />3b. Phone No. (include area <br />970-878-3674 <br />Title: Manufacturi Lag Director <br />Title: <br />Office: <br />Date: <br />Title 18 U S.C. Section 1001 and Title 43 U.S.C. Section 1212, make it a crime for arty person knowingly and willfully to make to any <br />department or agency of the United States airy false, fictitious or fraudulent statements or representations as to any matter within its jurisdiction. <br />(Instructions on page 2) <br />THIS SPACE FOR FEDERAL OR STATE OFFICE USE