Flowing Hole Report for Geophysical Operations Program Licensee: License No.: Program Permittee: Permit No.: Approval Number: Water or Gas: Prospect Name: Include shot point map for the relevant quarter section, indicating line(s) and shot point number(s) m South Location: Section: , Township: , . Latitude & Longitude NAD m West and degrees of the Northeast Corner of Range: , . minutes W: Meridian . seconds degrees . minutes seconds Note: NAD Format Must Be Indicated Date Drilled: Date Shot: yyyy Depth of Hole: mm Charge Size: yyyy m mm kg dd Origin of Flow: litres per minute Estimated Flow Rate: Date Plugged: dd By: yyyy mm dd Specify how hole was plugged: Remarks (e.g., bags of cement/bentonite, bladder and depth, pipe cut off below ground, successful or unsuccessful [flow rate], etc.) Contact Person: Phone: ( ) (please print) Please complete in accordance with sections 46 and 47 of the Exploration Regulation (AR284/2006) and forward to: Alberta Energy Regulator Twin Atria Bldg., 4th Floor 4999 – 98 Avenue Edmonton, Alberta T6B 2X3 e-mailing this form to exploration@aer.ca Alberta Energy Regulator Twin Atria Building, 4th Floor, 4999 – 98 Avenue, Edmonton, Alberta T6B 2X3 Page 1 of 1