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K <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 />9Plugged dry hole, method of plugging: �F (*mfmr_ <br />-%v"Att- ILI LEMtrAr T-jz'j j_►t_ <br />-A . <br />Depth at which concrete plug set: feet below ground surface. <br />❑Sealed Hole: <br />FINeat Cement Grout, top to bottom: grout mixture used: <br />F]Neat Cement Grout, interval grouting: grout mixture used: <br />B. <br />C. <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: <br />Type of surface plugging used: <br />Depth at which plug set: - feet below ground surface, <br />Method: <br />see. <br />Vkher 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 />CONVERSION TO A WATER WELL <br />State Engineer's Permit No.: <br />County Where Well is Located: <br />Water Well Use: <br />(attach copy of permit) <br />METHOD OF REG'LAIMIXG DRILL SITE DISTURBANCE: SITP- 'N Sir 1iZE4AAQ-eiN <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 />?9-X-S,beNr <br />Name of Operator's Representative: Title: S(AN)" CjAN GC0S%MV%'mS LL(-. <br />Signature of Operator's Representative: <br />Date: <br />M:tiiiin�,ihart.-',Pj-(>specting FormsN)Jf Abandonment Final RptAx <br />