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2 <br />Complete Pne (1) of Either Subsections A or B; and Subsection C. <br />A. PERMANENT ABANDOXMI ENT (Check the appropriate box and provide information) <br />F-1 Plugged dry hole, method of plugging: <br />Depth at which concrete plug set: feet below ground surface. <br />FX]Sealcd 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 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 />;___�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.: (attach copy of permit) <br />County Where Well is Located: <br />Water Well Use: <br />C. METHOD OF RECLAIMING DRILL SITE DIS'1 U AN ' <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: Jerald Schnabel <br />Title: President <br />Signature of Operator's Representativ 4-44-Lgate: Z'4 t <br />WminUneTrospecting Forms`,DH Abandomnenjil .dos <br />