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P2014-004 SITE #4 <br />Complete yOnt (i f Either Subsections A 91 B; and Subsection. C. <br />A. P ENT ABANDONMENT (Check the appropriate box and provide infortnation) <br />Plugged <br />y hole,method of plugging- tlT Lern A'AVfpl v4 u r <br />ie. / ," Z Y7 Fe <br />Ine,i <br />9 el04! Vf C <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 />Inwrvuls grouted (feet beneath ground surface, method and t=cnals): <br />❑Abandonrrmt Fluid Mixture (Such as Sodium Bentonite with Polymer) Brand. Name,- <br />Marsh <br />ame: <br />Match Funnel viscosity of abandonment fluid: sec. <br />Type of surface plugging used: <br />Depth at which plug set: feet below grotmd, surface, <br />Method: <br />Omer inethod used with approval of. the Division of Ri clamadon, Mining and Safety; describe in <br />detail method wd materials used on a separate attadhed sheet. <br />B. WNYFsMLQN ]:0 A WATER'1�4' IX <br />State Engine c s Permit No.: <br />County Where Well is Located: <br />Water Well Use: <br />(attach ropy of permit) <br />C. MMOD OF RECLAIMING D L I E DM' -U ANCE: Initial reclamation. smoothing <br />and cleaning of the §A h,. 5 been accgmplished–Saeling and sryingaillstari�pring <br />The Operator who conducted the prospecting drily operation states That the information set forth hereupon is true to the <br />best of their knowledge. <br />e <br />Name of Operato?s Representative:�lr o/ �! n _ Title: �A/1,�e cf scPIry Sd/ <br />Signature of Opemtor's Representative: — -- Date: <br />M:vninsharclPraspcctmg (kwmeOl I hbaWbmwa Vigal RpOm <br />