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i I <br /> G <br /> Complete 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 /> 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 /> xher 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. i 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 UISTURBANCE: 3:(--f----tyL' <br /> The Operator kvho conducted the prospecting dr)it operation states that the information set forth hereupon is true to the <br /> best of their knowledue. <br /> N { <br /> �me of Operator's Representative: <br /> C�Sit�*natire of t)i�erato7's R�-presentative: -.. - ---- Date: <br /> lit,nft`sharOProspecdng Fomis`d)H Abandonment Final Rpt.doc <br />