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r <br />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: bR %X M.oIE Pw (. e fl w NTH �• 3 yD3 of <br />Depth at which concrete plug set: <br />❑Seated Hole: <br />FINeat Cement Grout, top to bottom: <br />6 <br />feet below ground surface. <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 />Other 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 />D. 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. METffQQ, OF RECLAIMING DRILL SITE DISTURBANCE: S + TF- <br />A t iZE 4 Rq til t`L> <br />AND rSEEflE� �w tTH........A�Q �`IA a .w <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 />�S2�S�Dt�Nr <br />Name of Operator's Kepresentative: f �1fl lLac w�S N Title: SkA mNw keAk 6foS,40it es. <br />Signature of Operator's Representative : t�l Ln_.... . S v~--- Date: <br />a q 2 0 t 3 <br />M:Aminisshare4Prmpectrng Forms011 Abandonment Final Rpt.doc <br />