Laserfiche WebLink
G <br /> Con 1plete 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 /> �;, <br /> Depth at which concrete plug set: .,� feet below ground surface. <br /> ZSealed 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 /> ether 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 WEL[. <br /> State Engineer's Permit No.: (attach copy of permit) <br /> County Where Well is Located: <br /> Water Well Use: <br /> C" METHOD Ok RECLAIMING DRUA. SITE DISYt;-KBANC:E: <br /> The Operator-vvho conducted the prospecting dri li operation states that the information set forth hereupon is true to the <br /> best of their knowledge. <br /> Name of Operator's Representative: I -_ - _ Title: <br /> Si�nature of 0peTatc `s Representative: ,_-,,, t/l f- __-- --- Date: ..-.. _-a 1_ 1 j.- <br /> 1vi:�biin'share%l'rospectmg Fomts'1)11 Ahandonment Final Rpt.doc <br />