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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: I -TZOn� of No\E 4Lv 44e b w,-% % 17.44 RA% <br />A^%X V'Y*tb 8v bNNNOMA- REMA'All 19o\E M\Vb fiAoM SvI�fACE w►TH ti 3 yp3 ucMe r <br />Depth at which concrete plug set: 0 feet below ound surface 'DEl.vt�R�D 8 T14L f <br />Sealed Hole: <br />FINeat Cement Grout, top to bottom: <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 />W�ther 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 RECLAJMING DRILL SITE DISTURBANCE: s % re Tv �I V RE 4 RADEA <br />X 23,o.'O. A!' <br />?��s � c. -1q8► -918 , <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: _ /\N!HiZI-- W. S(AN\vN Title: Coq%- (itoSCkV% E1, <br />Signature of'Operator's R.epresentative:. _� Ac \'. S t',,,. ..'- Q % 7.o ]%I <br />_ - _,.....................,..._.W_ .__� _.__..__.._.......___- _._._.... Date: <br />M:tminLshare\Prospeaing FOMS A-1 Abandonment Final kpt.doc <br />