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M Lo aaoS <br />Complete Ofe (1) of Either Subsections A gr B; and Subsee don C. <br />a. P (Check the appropriate box and provide in(orrnatiem) <br />) Plugged dry hole, method of plugging: <br />Depth at which concrete plug sat; feat bellow ground surface. <br />( ) Sealed Holo: <br />( ) Ned Cement Grout, top to bottom. grout mixture used: <br />( ) Neat Cement Grout, interval grouting: grout mixture used: <br />Intervals grouted (feat beneath ground surface, nzffiod and materials): <br />N) Abandonment Fluid Mixture (Such as Sodium Bentonite with Polymer) Brand Name: ALIviiae <br />CCV%A, en.`t <br />Marsh Funnel viscosity of abandonment fluid: <br />Type of surface plugging used: C eti.-( <br />Depth at which plug set: r a — feet below groemd surface, <br />Method: �y. <br />Other method used with Approval of the Division of Reclamation, Mining and Safety; tlescri6e in <br />detail method and materials used an a separate attached sheet. <br />B. =k7MLQN TO A WATER Mz <br />State Engim;ees Permit No.: <br />County Where Well is Located: <br />Water Wen use: <br />(attach COPY of permit) <br />C. M1wTM,QF <br />RZO Ain_ <br />M PR_> <br />SxTE <br />D>ESTUItBAN ccs_ <br />The Operator who conducted tire✓ prospecting drill operation states that the infonnation set forth hereupon is trite to the <br />best of their knowledge. <br />Name of Ope rotor s Representative: Charles V. Muedioff Title: Vice presNott <br />Signature of Operator's Repre rotative: Datc: <br />�U;%nIiftWLIM4NWPCXdng rUMUM)H Abwuk m mt Firdtt RptAx <br />