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G <br /> Complete One(1)of Either Subsections A or B:and Subsection C. <br /> A. PEILNIANENT ABANDONMENT(Check the appropriate box and provide information) <br /> Plugged dry hole,method of plugging: - <br /> Depth at which concrete plug set: _ feet below ground surface. <br /> Sealed Hole: <br /> Neat Cement Grout,top to bottom: 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, MET-HOD OF RF,(-I1AIN1ILNG DRII.L SI"!E DtSTt'RBA iCE; /r --�� - -----..__.--._--.-- <br /> The Operator who conducted the prospecting driii operation states that the information set tbrth hereupon is true to the <br /> best of their knowledge. <br /> ..Name of Operator's Representative: _ � � __,_ Title: _ <br /> t }aerar ;` cprecrttive: .._-`� ;a`•�- „ i �` � — Date:ntttrt of ilStg <br /> -- t"' -- <br /> titianinsharc+Yru>pewunL t-ome`Oli Ahandonmenn Final Kpt.duc <br />