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z <br />Complete One (1) of Either Subsections A or B; and Subsection C. <br />A. PERMANENT ABANDONMENT (Check the appropriate box and provide information) <br />Plugged dry hole, method of plugging: BoTroM o!r Hole "L- 14c,ED 141TK �O e�A�. CEMyvT <br />M%'A ►3 DS)'\ 1t1RS. M*lK1N %jot e FNLL b W. Tla. - Z.5 %'l of C-hMlNT biL1Vek� <br />Depth at which concrete plug set: O feet below ground surface. Fit0m, S%JQ-ff U <br />Sealed Hole: <br />Neat Cement Grout, top to bottom: grout mixture used: <br />FINeat Cement Grout, interval grouting: grout mixture used: <br />Intervals grouted (feet beneath ground surface, method and materials): <br />❑Abandonment Fluid Mixture (Such as Sodium. Bentonite with Polymer) Brand Name: <br />Marsh Funnel viscosity of abandonment fluid: sec. <br />Type of surface plugging used: <br />Depth at which plug set: _ feet below ground surface, <br />Method: <br />Vther method used with approval of the Division of Reclamation, Mining and Safety; describe in <br />detail method and materials used on a separate attached sheet. <br />B. CONVERSION TO A WATER WELL <br />State Engineer's Permit No.: (attach copy of permit) <br />County Where Well is Located. <br />Water Well Use: <br />C. MET OD t{ RECLAIMING DRILL SITE ]DISTURBANCE: SITE 3E ,iZ�c,S?�DEp Rn� <br />SeED w 1 __.___ 3E�ct n► o � <br />The Operator who conducted the prospecting drill operation states that the information set forth hereupon is true to the <br />best of their knowledge. <br />Cm r <br />Name of Operator's Representative: +v10 N ^ Citle: S�+a\oN <br />Signature of Operator's Representative Z �v , t.4 Q �� Date: g 12 n t 3 <br />Mninin'share4Prospwing rorms'01I Abandonment Final Rpt.doc <br />qk <br />