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Id <br />Complete One (1) of Either Subaiuetions A or B, and Subsection C. <br />A. PERMANENT ABANDONMENT (Cheek the appropriate box and provide information) / <br />Plugged d,y hole; ,,,ethos of plugging: `� puna d dri 1 le d 0at44, v�r� ay in Yln 1 <br />G'onere><e D I c► 4" p�G n; Qbr�ye rallncl <br />Depth at which co....;,.te plug Net: <br />`-Vsealed Hole: <br />❑Neat Cement Grout, top to bottom: <br />feet below ground surface. <br />grout mixture used: 0-u ,n$-, and <br />Hr4eat Cement Grout, interval grouting: grout mixture used: /OD / ins, C' onr—,re4e m, y <br />Intervals grouted (feet beneath grow„d ourfacu, method and materials): <br />P hn tJ Q rte,➢IrIC p <br />❑Abandonment Fluid M;rtu.c (Such as Sodium Bentonite with Polymer) Brand Name: <br />I <br />Marsh Funnel vi5casAy of abandonment fluid: NIA sec. <br />Type of surtace plugging used: <br />Depth at wh;eh plug set: Feet below ground surface, <br />Method: <br />Ithe, Method used witn approval of the Division of Reclamation, Mining and Safety; deauribe ;„ <br />detail method and materials used on a sepa,ate attached 5huvt. <br />B. CO_NVE>0ION TO A WATER WELL <br />State Enginee,'s Pc u. t No.: NlT (attach copy or permit) <br />County where We'_! is Located: <br />water Well Use: <br />C. METHOD OF RECLAIMING/�D►►RILL SITE DISTURBANCE: _ Up�ele 1—� 1 / <br />�2Ie.ke4 3n0reeL-c D0- on .pmt.ree Ctr)LpJCL <br />The Operator who conducted the Y,vapect;„g d,;11 upmat;vu state., that the information set Fortn hereupon is true to the <br />best of their knowledge. <br />Name of Operator's ReNresentative:/,Q /— r <br />V C C,/<.e- Title: C4c,,7'0 <br />Signature of Operator's Representative:�'iiL[� _ c c. 6-- Date: /- 15 —/6"*' <br />M:�mWshanEPrruspc,ing ranns\Dtl Abandunment Final Rpt.doc <br />