Laserfiche WebLink
2 <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: t3aTropn of Wol� � otep w,� 8b_Qfl�. �`MCr�T M <br />QJMPeD 3., UR,UtfZS RE MAIN�NC� llolE F�IIF,� w�iH N 3 4,D3 of t.iMl`7�1T �Euv� ip F*;.M <br />Depth at which concrete plug set: <br />❑Sealed Hole: <br />Neat Cement Grout, top to bottom: <br />feet below ground surface. S,"P t-r a'1 rrwty, , <br />grout mixture used: <br />Neat 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 />16ther 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. METHOD OF ItEC'LAIMING DRILL SITE DISTURBANCE: SATE <br />SEEA�.._ti_►? �'L�- __��.�VtD._.M�_ ..__...._ .._ ...._KoL..�........._ 0 0_.' �.._ . <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 />1 �SZ,ES��jENt' <br />Name of Operator's Representative: M Aft1L_ w , S�An�lo N Title: <Arv\on4 .CoAI <br />Signature of Operator's representative: ,`(� o. �.- Date: 4 r t4 11 <br />M:trnin1Aare4Prospecting forms`! r Abandomnent Filial Rpt.doc <br />*k <br />