2012-10-12_REPORT - P2009025

• Permit No: P2009025
• IBM Index Class Name: REPORT
• Doc Date: 10/12/2012
• Doc Name: ANNUAL FEE/REPORT
• From: BLACK RANGE MINERALS
• To: DRMS
• Email Name: TC1
• Media Type: D
• Archive: No

Drill Hole Completion Form
or
BLACK RANGE
N r n
Hole Number: 4N)N.30
Completion Date:
Total Depth: (
Drilling Company: 5
Head Driller: ` �/ swt,_j -1,
Instructed By Geologist To
Cement From (ft):
Total Plug Gel
Instructed: lb/ be--5/
Actual Use: ? Sv 1 br
Total Cement
Instructed: 9 /do / b / b`1 J
Actual Use: 7 r / 1,/
Geologist's Signature:
Head Driller Signature:
dir
Cement To (ft): o
0`6x } 2,0 I I