CORE SAMPLE SUBMISSION FORM (PETROLEUM)

COMPANY DETAILS: Date: _______________________________________Operating Company: _____________________________ Contact Name: _______________________________Postal Address: _________________________________ Phone No: ___________________________________ ______________________________________________ Fax No: _____________________________________ ______________________________________________ Email: ______________________________________

DRILLING DETAILS: (Please complete one form for each hole drilled)

Locality/Prospect Name: __________________________ GDA94 UTM Coordinates:Well Name/No.: __________________________________ _____________________________________m EASTDepth of Hole (m): ________________________________ ____________________________________m NORTHDrilling Completion Date: ___________________________ Zone: _______________________________________Title Type/No.: ___________________________________ Source of Coordinates (eg. Hand held GPS)

Geological Province: _____________________________ ____________________________________________1:250K Map Sheet Name: _________________________ ____________________________________________1:100K Map Sheet Name: _________________________ ____________________________________________

SAMPLES TO BE SUBMITTED:

Core Intervals: ___________________________________ Core Diameter: ________________________________ ______________________________________________ No. of Core Trays: _____________________________ ______________________________________________ No. of Pallets: _________________________________ ______________________________________________ ______________________________________________ No. of Cutting Samples: _________________________ ______________________________________________ ______________________________________________ Comments (e.g. 5 trays missing, trays 1-3 damaged)________________________________________________________________________________________________________________________________________________________________________________________

Cutting Intervals:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Northern Territory Government, 22/01/2015

DEPARTMENT OF MINES AND ENERGY

DEPARTMENT OF MINES AND ENERGY USE ONLYReport No.: Rack Location: Recorded by.: Date Recorded:

NOTE: Form to be submitted to Core Facility Manager with sample in accordance with the Geological Sample Submission Procedure (Core and Cuttings) procedure.