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L <br /> Complete One(1)of Either Subsections A or B:and Subsection C. <br /> A. PERIVIA.NENT ABANDONMENT(Check the appropriate box and provide information) <br /> Plugged dry hole,method of plugging: <br /> Depth at which concrete plug set: G) 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: _�t — _— <br /> her 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. METHOD OF RECLAIMING DRILL SITE D11-JURBANC.E: <br /> The Operator who conducted the prospecting dri 11 operation states that the information set forth hereupon is true to the <br /> best of their knowledge. <br /> Name of Operator's Representative: Title: <br /> -- - - -- �F-- - - ---- <br /> Signature of( pcTator's Representative: __-_--� �/ - �� -- ----------- bate: -- . <br /> Winie,shareTrospcoing Fornis,DI I Abandonment Final Rpt.doe <br />