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Complete ne (l) of Either Subsections A or B; and Subsection C. <br />A. PER: AUNENT ABANDONMENT (Check the appropriate box and provide information) <br />Plugged dry hole, method of plugging: <br />Depth at which concrete plug set: feet below ground surface. <br />Sealed Hole: <br />ENeat 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: <br />Type of surface plugging used: _ <br />Depth at which plug set: feet below ground surface, <br />Method: <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 RECLALMING DRILL SITE DISTUIWANM <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: Jerald Schnabel <br />Title: President <br />Signature of Operator's Representativ later <br />W Vnin'shereTrospecting Forms1DH Abandonment F al ptdoe <br />