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2 <br /> Complete One(1)of Either Subsections A or B.and Subsection C. <br /> A. PE&MANENT ABANDONMENT(Check the appropriate box and provide information) <br /> ❑Plugged dry hole,method of plugging: <br /> �Dgpthht which concrete plug set: feet below ground surface. <br /> le ole: <br /> Neat Cement Grout,top to bottom: grout mixture used: Sjv,�G%-,zu+ koD <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 /> lz�ther 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. MET OD OF REC:LAIMIING DRILL SITE DISTURBANCE: <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 Operator's Representative:�ACS? ` �~N a _ Title: /��4,j <br /> Signature oft}perator's Representative: ..... .- . .. .... ._ bate: <br /> Wmin�shareTrospLOng forms\DH Ahandomnent Final Rpt.doc <br />