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Form No. STATE OF COLORADO. OFFICE OF THE STATE ENGINEER <br />GWS-09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />4/2012 (303) 868 -3581 Fax (303) 886 -3589 stfammitimagagiatfugm <br />WELL ABANDONMENT REPORT <br />Use to report plugging and sealing of pem'udted wags, mondoring and other Ades. This form can be <br />computer generated, typed or printed in blade or blue ink Instructions and plugging standards are on <br />reverse side of form <br />Well Permit Number of the well being plugged or <br />III File Number MN- Hole ID f1/Name B12 -3 <br />Individual/Company resoonsible for oluaaina and sealina the well: <br />Names) GODBE DRILLING LLC. <br />Mailing Address 62802 OHLM ROAD <br />City, St., Zip MONTROSE, CO, 81403 <br />Phone (area coda & no.) 970 -240 -6106 Email. ll(lodba)aol.com <br />Well (Hotel Owner <br />NAME(S) GOLD HILL MINERALS <br />Maibng Address, City, St, Zip PO BOX 191127. MIAMI BEACH, FL, 33119 -1127 <br />ACTUAL WELL LOCATION; County BOULDER <br />Property Address, City, St, Zip 3i(4 . d et" 1 d64 kJ. ZR44esto...4. , CO , 80 4-Ss <br />at 1 /4of the s /4 Sec. 2j 2— 0N.or Cl S., Range 72 ® E. or 0 W., G. 4 P.M. <br />Distance from Section Lines . 3 3 D Ft. torn ga N. or C S. d�� Ft from E. or 0 W. Line. <br />SWdlvisbn Name Lot , mom , Filing/Unit <br />Optional: GPS well location iMcxmaiion in W M format, You must check GPS unit for required settings as follows: <br />Format must be UTM, zone 12 ❑ or zone 13, ; Units must be meters; Datum must be NAD83; Unit must be set to true north <br />Easting 5 33 9 Northing 4; 1 f-4-6 2.81. <br />1 (we) report the existing well (hole) was plugged and sealed on the date of 09/20/2012 for the following reason(s): <br />❑ The well was plugged and sealed as required under Well Permit Number <br />0 The well was not in use and was plugged and sealed <br />m Other (please explain) CORE DRILL BORE HOLE ( ALL CASINGS REMOVED) <br />' The wall was plugged with the following materials placed at the inrticated intervals: <br />Amount and Type of Material Method of Placement <br />280 GAL. DRILL CUTTINGS <br />PUMP DOWN <br />7-50# SACS (HIGH SOLIDS BENTONITE) PUMP DOWN <br />PORTLAND TYPE 1I CEMENT <br />Intervals of casing removedlripped in feet <br />PLUG {all 10' AND BACKFILL from 10 feet to 0 feet <br />Report must be signed or name entered by person who performed the well plugging work or by the well owner if thls person is unknown or <br />not reachable. I (we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge. <br />Sign or enter full name <br />If signing print name & title Date (rnm/dd/yyyyy) <br />I BRIAN MANTEL GODBE DRILL FOREMAN <br />It is the responsibility of the wall 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 />For Office Use Only <br />Phone (include area code) 305 - 726 - 7752 <br />Interval <br />from 600 feel to 122 feet <br />from 122 feet to 10 feet <br />from feet to feet <br />09/20 /212 <br />