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P2014-004 SITE #4 <br />Complete QW (I f Either Subsections A 91 D; and Subsection C. <br />A. T (Check Ow appropciatc box and provide information) <br />Plugged dry hole, method of plugging: n %!__CCm M L b "out' p l v4 u% <br />e <br />B. <br />C. <br />Depth at which concrete plug set: _ <br />❑Sealed Hole: <br />Neat Cement Grout, top to <br />feet below ground surface. <br />bottom: grout mixture used: <br />❑Neat Cement Grout, interval grouting: grout mmture used: <br />Intervals grouted (feet beneath ground surface, method and materials): <br />❑Abandonment Fluid Mimm (Such as Sodium Bentonite with Polymer) Brand Nam: <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 />flter method used with approval of the Division of Reclaumon, Mining and Safety, describe in <br />D <br />detail method and matenals used on a separate attaebed sheet: <br />+ill' �'l a a xxy #:A <br />State fingincces Permit No.: <br />County Where Well is Located: <br />Water Well Use: <br />(attach copy of peralit) <br />NgLI OD OF RECLAMING pML SITE D�TUSCE: Initial reclamation, smoothing_ <br />and cleaningofthe site ne accompll� hid, ,Seeding and sprat inng win start Spring.9 <br />The Operator who conducted the prospecting drill operation states chat tha information act forth hereupon is true to the <br />best of their knowledge. <br />Q r <br />Name ofopemioes Representative: RW k2o/'��n Title: Awe <br />Ly <br />Signature of Oprcatoxs Rcpr,�tttativc✓� --- - ar <br />Date, � d2[�— i <br />M:VnW,A=lProspvcft FamuAN I Abowb om P-irul Kptdoc <br />