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Page 3 of 3 <br />Marsh Funnel viscosity of abandonment fluid: sec. <br />Type of surface plugging used: - - - .. <br />Depth at which plug set: <br />feet below ground surface, <br />Method: I <br />® 2d. Oilier method used with approval of the Division of Reclamation, Miming 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.:I- I (attach copy of permit) <br />County Where Well is Located: <br />Water Well Use: <br />V. METHOD OF RECLAIMING DRILL SITE SURFACE DISTURBANCE: <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 />Consulting Geologist <br />(Title) <br />3/2312018 <br />(Date) <br />