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2 <br />Complete ne (1) of Either Subsections A or B: and Subsection C. <br />A. PERMANENT ABANDONMENT (Check the appropriate box and provide information) <br />F]Plugged dry hole. method of plugging: _ <br />Depth at which concrete plug set: feet below ground surface. <br />FX Sealed Hole: <br />ElNeat Cement Grout, top to bottom: grout mixture used: cement and bentonite <br />Neat Cement Grout, interval grouting: grout mixture used-- <br />Intervals <br />sed: <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 />173ther 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 TOA NVATER„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 OFECLAIMING DRILL SETS DI8TLJRBAt\CE• <br />Tire 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: Jerald Schnabel <br />Title: President <br />i <br />Signature of Operator's Representative: Date: <br />M:Uninlshaae�Prospecting Focrms`d)H Abandonment Fin i pt.doc <br />