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N <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 />RV Plugged dry hole, method of plugging: <br />Cement <br />Depth at which concrete plug set: 2 <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 viscosity of abandonment fluid: <br />Type of surface plugging used: <br />Depth at which plug set: <br />Method: <br />feet below ground surface, <br />sec. <br />�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.: <br />County Where Well is Located: <br />Water Well Use: <br />C. METHOD OF RECLAIMING DRILL SITE DISTU'RBANCE: <br />No Disturbance -See Photos <br />(attach copy of permit) <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: <br />Kenneth Schaaf Title: Authored Representative <br />5p��3�// <br />Signature of Operator's Representative: ,�< "-- �•.,�..,.� Date: ,---- _____��� <br />M: +min share\Prospming Foems\DH Ahandomnent Final Rpt.doc <br />