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Page 3 of 3 <br />Marsh Funnel risemity of abandonmernt fluid: sec. <br />Type of surface plugging used: <br />Depth at which plug set: <br />feet below ground surface, <br />Methal: <br />® 2d. Other rnethod 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 Enginm-es Permit No.. (attach copy of permit) <br />County Where Well is Located: <br />Water Well Use: <br />V. METHOD OF RECLAIMING DRILL SITE SURFACE DIS'T'URBANCE: <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 />l:rr <br />{Name <br />(Signature <br />= Consulting Geologist <br />ix+e} (Title) <br />312312018 <br />ative) (Date) <br />