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mw 17go(-( <br /> 2 <br /> CwVfete One(1)of Either Subsections A gr B;and Subsection C. <br /> A. PER} &ffi&NT ABANDONM, MT(Check the appropriate box and provide in(arsuation) <br /> ( )Plugged dry hole,meth of plugging: <br /> Depth at which concrete plug set: feet below ground surface. <br /> f )'Seeded Hole: <br /> ( )Neat Cen-wnt Grout,top to bottom: grout mixture used: <br /> ( )Neat Cement Grout,interval grouting: grout mixture used: <br /> intervals grouted(feet beneath ground surface,method and materials): <br /> 04 Abandonment Fluid Mixture(Such as Sodium Bentonite with Polymer)Brand Name: AWA +P <br /> f . <br /> Marsh Funnel viscosity of abandonment fluid: sec. <br /> Type of surface plugging used- Pjtit..en � <br /> t <br /> Depth at which plug set: 1 feet below ground surface, <br /> Method y��? D L J r.J Ra 5 `� (4o e-e <br /> { )Other method used with approval of the Division of Reclamation, Mining and Safety;describe in <br /> detail method and materials used on a separate attached street. <br /> B. CONVERSION TO A WATRR HALL <br /> State Enghie f's Permit No.: (attach copy of permit) <br /> County Where Well is Located: <br /> Water Well Use: <br /> C. 1VI, M0 }QF RECLAL'VBN'G DRILL SITE MIUBWCR: _ <br /> The Operator who conducted the prospecting di iii operation states that the information set forth hereupon is true to the <br /> best of their knowledge. <br /> Name of0peratoes Representative: Charles V.Muerhoff Title: Vice Presided r <br /> Signature of Operator's Representative: _�._ _ Bate: <br /> -U;\minWjmtV'Mpxting Fem'3\01i Abandomacnt Mad Rptdoe <br />