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2 <br /> Complete One(1)of Either Subsections A or B;and Subsection C. <br /> A. PERMANENT ABANDONMENT(Check the appropriate box and pro�1de information} <br /> ��J-HvO <br /> ©Plugged dry hole,method of plugging: /V4-1 i v Sn <br /> Depth at which concrete plug set: feet below ground surface. <br /> Sealed Hole: <br /> Neat Cement Grout,top to bottom: grout mixture used: <br /> Neat Cement Grout,interval grouting: grout mixture used: <br /> Intervals grouted(feet beneath ground surface,method and materials): <br /> Abandonment Fluid Mixture(Such as Sodium Bentonite with Polymer)Brand Name: <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 /> Method: <br /> Wither method used with approval of the Division of Reclamation, Mining and Safety; describe in <br /> detail 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 /> C. :METHOD OF RECLAIMING DRILL SITE DISTI;RBANCE: N �- <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 /> V <br /> Name of Operator's Representative: I 6 �F9�V, 1(/ <br /> � Title: . _rA Y-9 _ <br /> Signature of'Operator's Representative; Date: <br /> M:-min'sharc,Prospecting Fomts`lll I Abandonment Fin pt.doc <br />