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Form No. <br />C)WS-09 <br />4/2012 <br />WELL ABANDONMENT REPORT <br />Use to report plugging and sealing of permitted wells, monitoring and other holes This form can be <br />compula' generated, typed or printed in black or blue inIc. Instructions and pugging standards are on <br />reverse side of form. <br />Well Permit Number of the wol1 being plugged <br />MH File Number MH- Hole ID *!Name B12-8 <br />Individual/Company responsible for cluoalna and sealina the well: <br />Naane(s) GOOSE DRILLING LLC. <br />ple;I;� Address 62802 OHLM ROAD <br />city, St, Zip MONTROSE, CO, 81403 <br />Phone (area code & no) 970 - 240 -6106 Emai: jjgodbeaaol.com <br />Intervals of casing rernovedlripped in feet <br />Sgn or enter full name If signing pnnt name & title <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only <br />821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />(303) 866 -3581 Fax (303) 866 -3589 dwrDermItsonlinet@►state.co.us <br />BRIAN MANTEI GODBE DRILL FOREMAN <br />or <br />10/08/2012 <br />Well (Hole) Qwner, <br />NAME(S) GOLD HILL MINERALS Phase (include area ) 305- 726 -7752 <br />Mailing Address. City. St. Zip PO BOX 191127, MIAMI BEACH, FL, 33119 <br />ACTUAL WELL LOCATION County BOULDER --�~ <br />Property Address, City. St, Zip 34> 4v erl all At.) GUKPB icuif CO • e , 45 <br />N6 1/4 of the S W1/4, Sec, 2.1 Twp. )— 1 N. or f S., Range 7-- © E. or Ei w. la's P.M. <br />Distance from Section Lines 2 Ft. from is N. or C s. 1, 2O Ft from DE or © W Line. <br />Subdivision Name Lot . Block Filing Unit <br />Optional: GPS we location information in UTM format You must check GPS unit for required settings as follows: <br />Format must be UTM, zone 12 C7 or zone 13 Iii‘; Units must be meters; Datum must be NAD83; Unit must be set to true north. <br />' Eaetirg 4/4 3) Z Northing 4, %�, 3410 <br />I (we) report the existing waft (tole) was plugged and sealed on the date of 1 010 8/201 2 for the following reason(s): <br />ID The well was plugged and sealed as required under Well Permit Number <br />❑ The well was not in use and was plugged and seated. <br />le Other (please explain) CORE DRILL BORE HOLES ALLSASINGS REMOVED) <br />The well was plugged with the following materials placed at the indicated Intervals: <br />Amount and Type of Material Method of Placement Interval <br />210 GAL. DRILL CUTTINGS PUMP DOWN from 450 feetto 90 feet <br />5-50# SACS (HIGH SOLIDS BENTONITE) PUMP DOWN from 90 feet to 1 0 feet <br />PORTLAND TYPE 11 CEMENT PLUG ) 10' AND BACKFILL from 10 feet to 0 feet <br />from feet to feet <br />Report must be signed or name entered by person who performed the vaeil plugging work or by the well owner if this person is unknown or <br />not reachable_ I (we) have reed the statements made herein, know the contents thereof, and that they are true to my (our) knowledge. <br />Date (mm/dd/yyyyy) <br />It is the responsibility of the well owner to have the well/hole properly plugged and sealed. The Well Construction Contractor <br />is responsible for notifying the owner of this requirement. <br />