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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: <br />® 2d. Other rnethod used with approval of the Division of Reclamation, Mining and Safety; describe in detail <br />nnethW and nuftrials used on a separate attached sheet- <br />B. <br />heer <br />B. CONVERSION TO A WATER WELL <br />State Engi x*Ys Permit No.: (attach copy of permit) <br />County VAme Well is Located_ <br />Water Weli 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 />(Tide) <br />3123/2018 <br />(Date) <br />