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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:. %orSV nn of 1q \E ?Lv c,c.Va w ts_y 12O 4A►- (.E M�°rvT <br />A tX TioMAi %h Dit, \�ttiRS RcMA ++.t Iry 4 Y�Q\C It t-%-e b �+ ^' 3 `IP3 eF CEMM'r <br />.._ Ol t.tvt'>lm <br />Depth at which concrete plug set: <br />❑Sealed Hole: <br />FINeat Cement Grout, top to bottom: <br />feet below ground surface. Fflaw Sv+2f*t,F N,\ T v t.tc <br />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: <br />Type of surface plugging used: <br />Depth at which plug set: _ feet below ground surface, <br />Method: <br />sec. <br />Vpther 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.: <br />County Where Well is Located: <br />Water Well Use: <br />(attach copy of permit) <br />C. METHOD OF REC.'LAIMIN`G DRILL SITE DISTURBANCE: S %-T -'_°_ .._.._-iz-e _(4uA.M <br />X._... - <br />��Mr+►T C- 1C1lb 1 <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 />Name of Operator's Representative: __MP Ric 1�., . S ��nt� o N `fitic: 5Lt►N \orv� C,o6�L G�oSv,�S Lac . <br />Signature of Operator's Representative: �„+, D <br />J,�- -- 9 /I Z`F ►3 <br />ate: _. ___.. _.1._.. _...1..._._.. <br />Wvnin'AareTrospeeting Forms!1)11 Abandonment Final Rpt.doc <br />0 <br />