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Page 3 of 3 <br /> Marsh Funnel viscosity of abandonment fluid: F sec. <br /> Type of surface plugging used: <br /> f yr�c t�ww►� <br /> Depth at which plug set: feet below ground surface, <br /> Method: <br /> Fq2d.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.: F <br /> (attach copy of permit) <br /> County Where Well is Located: <br /> Water Well Use: <br /> V. METHOD OF RECLAIN41NG DRILL SITE SURFACE DISTURBANCE: <br /> - Cam; "" FM"1144.IT <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 /> `)avyl E'f <br /> (Name,of Operator's Representative) (Title) <br /> j.2 �/-z 2016 <br /> (Si ature of Operator's Representative) f (Elate) <br />