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2 <br />Complete vne (1) of Either Subsections A or B; and Subsection C. <br />A. PERMANENT ABANDuNMENT (Check the appropriate box and provide <br />15. <br />dry hole, method of pluggit.g: <br />Depth at which concrete plug set: <br />Sealed Hole: <br />❑Neat Cement Grout, top to bottom: <br />fcUt beio W ground surface. <br />glu,ut nlrAtulC. usem: <br />❑Neat Cement GAUt, ;,rtvTvval grouting: grout mixture used: ,&_Q�l�.0h t-& ,_ <br />Intervals grouted (teet beneath ground surface, method and materials): dluzzx , <br />❑Abandonment Fluid Mixture (Such as Sodium Bentonite with Polymer) Brand Nance: <br />�lA <br />Marsh Funnel viscosity of abandonment fluid:� sec. <br />Type of surface plugging ubud: <br />Depth at which plug set: feet below ground surfs. e, <br />Method: <br />VPther method used .,;ih approval of thu L);v;b;tm of Reciamation; Mining and Safety; describe in <br />detail method and materials used on a separate attached sheet. <br />COrnVERSION TOA WATER_ WELL <br />State Engineer's Permit No.: i"l122 (attach espy of PC, init) <br />County where Well is Located: <br />Watar Well Use: <br />C. METHOD OF RECLA SUNG D <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 upeintvi's Repiesentat;ve: Title: D5t�j C'e ,,i <br />Signature of Operators Representative: �r� CVV C-- Date: / - / <br />Mnmin'AarePrOSpzring Form3DII Abanauml[CUL Final Rpi.aoe <br />