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i�r► <br />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: t�oiTar. 4a - CRrnT A <br />e r? ghe —U&% A- N t►a ( 01,L.F FILLED FRonA SVAf4Qf ^' 3 yO' UMCryT fltillYt'rLM <br />Depth at which concrete plug set: feet below ground surface. Sy Tew t1- <br />❑Sealed Hole: <br />FINeat Cement Grout, top to bottom: 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 />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 />�. 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. MET OD OF RECLAIMING DRILL SITE DISTURBANCE: SITE tb SE...__TU (4RADitb. - -_A"D <br />7- 30 —c3 ,f H G- 1RB1 —ol`� <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 />I�tES �pCNT <br />Name of Operator's Representative: S�iAN�or4 Title: .Sc>AN\ora ue#,� <br />Signature of Qperator's Representative: o • S Date: 9 / 24 1'3 <br />W' inin%sharetProspecting forms`,)! i Abandonment Final Kpt.doc <br />