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rncd DgDq <br />Complete OM (1) of Either Subsections A g B; and SubseWon C. <br />A. LPM&MM AVANVQMW(Check the appropriate box and provide int'cmnation) <br />( ) Plugged dry hole, method of plugging: <br />Depth at which concrete plug set: feet below ground surface. <br />f YSeg ed Hok: <br />( ) Neat Cement Grout, top to bottom: grout rnixtnrc used: <br />( } Neat Cement Grout, interval grouting: grout mixtum used: <br />humvals grouted (fleet beneath, ground surface, method and mammals): <br />(� Abandonment Fluid Mixture (Such as Sodium Bentonite with Polymer) Brand Name: &r S!%L JP <br />Marsh Funnel viscosity of abandonment fluid: k<- - sec. <br />TYPe of surface plugging used: { e t <br />Depth at which plug set: ,1 feet below g=wd surface, <br />Method: Ra A 5 .L 4p C <br />Other method used with approval of the Division of Reclatnation. Mining and Safety, describe in <br />detail method and materials used an a separate attached sheet. <br />B• ION TO A WAT= WELL <br />State Engineert Permit No.: <br />(attach copy of permit) <br />County Where Well is Located: <br />Water Well Use: <br />The operator who conducted the prospecting drill operation states that the information set forth hereupon is we to the <br />best of their knowledge. <br />Name of Operator's RepMsentstive: Ch&%8 V. Muehotf .Vice <br />Title. Presltiere! <br />Signature of Opemtoes Representative: Date: <br />�lwt;timinwm�uhnspeseir g Fwnulnli Almoelomm Plna3 Rp[.doe <br />