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G <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 /> Plug ged dry hole,method of plugging: <br /> Depth at which concrete plug set: feet below ground surface. <br /> INSealed 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: _see. <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"OD OF RECLAIMING DRILL SITE D1STLRBANC"E: <br /> Th Operator who conducted the prospecting drill operation states that the information set forth hereupon is true to the <br /> be- of their knowledge. <br /> Name of Operator's Representative:__M40AJ>_. 6 __ ,-k Title: <br /> Signature afOpemlor's Represzentative- �/ <br /> Mrmirishare+{'roslxcune Date- 31- <br /> I-omisll)l ANndonment Final Rpt.doc <br />