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Complete One (1) of Either Subsections A or B; and Subsection C. <br />A. PERMANENT ABANDONNIENT (Check the appropriate box and provide information) <br />Plugged dry hole, method of plugging: <br />Insert cuttings, plug with 5 ft concrete below collar <br />Depth at which concrete plug set: 6 <br />❑Sealed Hole: <br />❑Neat Cement Grout, top to bottom <br />feet below ground surface. <br />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 viscosixy of abandonment fluid: <br />Type of surface plugging used: <br />Depth at which plug set: _ feet below ground surface, <br />sec. <br />Method: <br />[Z]Dther method used with approval of the Division of Reclamation, reining and Safety; describe in <br />detail method and materials used on a separate attached sheet. <br />13. CONVERSION TO A 'YVATER WELL <br />State Engineer's Permit No.: <br />County Where Well is Located: <br />Water Well Use: <br />(attach copy of permit) <br />C. METHOD OF RECLAR)UNG DRILL SITE DISTURBANCE: <br />Spread. out cuttings scarify_,_and relyegetate area <br />The Operator who conducted the prospecting drill operation states that the information set forth hereupon is true to the <br />best of their knowledge. <br />Name of Operator's Representative: Glen Williams <br />Title: VP of Mining <br />Signature of Operator's Representative: � --emu bate: /...._...._/ 3_.__ <br />�f: min!shareil'rospecting Forms,Dl-1 Abandonment final Rpt.doe <br />