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2 <br />Complete One (1) of Either Subsections A or B, and Subsection C. <br />A. PER IANENT ABANDONMENT (Check the appropriate box and provide information) <br />Plugged dry hole, method of plugging: _ <br />Insert cuttings, plug w 5' concrete below collar <br />Depth at which concrete plug set: 6 feet below ground surface. <br />FSealed Hole: <br />Neat Cement Grout, top to bottom: grout mixture used: <br />A. <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 />IIJther 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 />Cl METHOD 0F RECLAIMING ING DRILL SITE DISTURBANCE: <br />Spread out cuttings, scarify, -and re- vegetate area. <br />(attach copy of permit) <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: Glen Williams - -- - .-- .-- �--- .__..- .- __ —_ -_ Title: VP Mining <br />5tstnatore ol�Opt.rator's ltepresentative � �GJ�G�? - Date: <br />Ni urn share,Piospcctmg Vormi 01I Abandonment I final Rpt doe <br />