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KI3 Page 3 of 3 <br /> Marsh Funnel viscosity of abandonment fluid: 17 sec. <br /> Type of surface plugging used: <br /> ;x--I M:J <br /> Depth at which plug set: t feet below ground surface, <br /> Method: y <br /> Fn2d.Other method used with approval of the Division of Reclamation,Mining and Safety; describe in detail <br /> 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 /> V. METHOD OF RECLAIMING DRILL SITE SURFACE DISTURBANCE: <br /> roc,S f CO� <br /> The Operator who conducted the prospecting drill operation states that the information set forth <br /> hereupon is true to the best of their knowledge. <br /> G <br /> (Nam of Operator's Representative) (Title) <br /> ( ature of Operator's Representative) (Date) <br />