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P2014-004 SITE #2 <br />2 <br />Complete Oct (d) of Either Subsections A or and Subsection C. <br />A. PE ENT ABANDONMENT (Check the appropriate box and provide information) <br />Plugged dry hole, method of plugging. 64J- tee" - 4 % Cr e�.e 1-V h C4:77�" 63 l'eej <br />CI �ur►Cr�c neap ce cat Cti�o✓Y- lv A r f z3e/plaJ syr q� e <br />Depth at which concrete plug set: r_ <br />❑Soled Hole: ' <br />0 Neat Cement Grout, top to bottom: <br />feet below ground surrace. <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: sec. <br />Type of surface plugging used: __ <br />Depth at which plug set: - , feet below ground surface, <br />Method: <br />DD.ther method used with approval of the Division of Reclamation, Mining and Safety, describe in <br />. rmthod and matteriais 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 />(attach copy of permit) <br />C. MI;' HOD OF i-ECLAIMING DRILL SITE DISTURBANCE: Initial r.�clarx ki�n,.srx�anthing_-_., <br />and cleaning of the site has been accomplished. Seeding and spray -in will start S rin ,2015. <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 />Signature of Operator's Representative: <br />M_,mKshare%Pmpwting rormgkbil Abandonment final itpt_doc <br />Title: - est su �✓v� S a <br />bate: <br />