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M t„? oao; <br /> z <br /> Complete One(1)of Either Subsections A gf B;and Subsection C. <br /> A. PERME4=T ABANDONMEN,3"(Check the appropriate box and provide informatfon) <br /> { )Plugged dry hole,method of plugging: <br /> Depth at which concrete plug set: feet below ground surface. <br /> ( )Bede d Hole: <br /> ( )Neat Cement Grout,top to bottom: grout mixture used; <br /> ( )Neat Cement Grout,interval grouting: grout mixture used: <br /> Intervals grouted(feat beneath ground surface,method and materials): <br /> OK)Abandonment Fluid Mixture(Such as Sodium Bentonite with Polymer)Brand Name:AQz&& .(e <br /> Marsh Funnel viscosity of abandonment fluid: P(1!5' see. <br /> Type of surface plugging used: CPM eX'( <br /> Depth at which plug set:_ (E t feet below ground surface, <br /> ;Method: R'-v imko !)a A,-I---' �&ds `4- Ho(-.e <br /> ( )Other method used with approval of the Division of Reclamation,Miming and Safety;describe in <br /> detail method and materials used on a separate attached sheet. <br /> W CONVERStON TO A WATER WELL <br /> State Engineer's Permit No.: (attach copy of permit) <br /> County Where Well is Located: <br /> Water Well Use: <br /> C. MMLO-2 1N D L§=D CE• <br /> The Operator who conducted the prospecting drill operation states that the information set forth hereupon is true to the <br /> best of their knowledge. <br /> Name of Operator's Representative: Chad"V.Muwhoff Title: Vtae PpesWNA <br /> Signature of Operator's Representative:_ __ Date: ....... <br /> -U.%ninWtan:kPmspecting t'umisU)H Abandonment Final Rpt.doc <br />