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�vl ca 000'5 <br /> z <br /> Complete One(1)of Either Subsections A 9Z B;and Subsection C. <br /> A. PERM NT BANDONMENT(Check the appropriate box and provide information) <br /> ( )Plugged dry hole,method of plugging: <br /> Depth at which concrete plug set: feet below ground surface. <br /> ( )Sealed Hole: <br /> ( )Neat Cement Grout,top to bottom: grout mixture used: <br /> ( )Neat Cement Grout,interval grouting: grout n*.ture used: <br /> Intervals grouted(feet beneath ground surface,method and materials): <br /> (k)Abandonment Fluid Mixture(Such as Sodium Bentonite with Polymer)Brand Name:kzan a, e <br /> Do ncue -(,e 1'{(3QS� c fwA'ee-A <br /> Marsh Funnel viscosity of abandonment fluid: see. <br /> Type of surface plugging used: c m ejP .-( <br /> Depth at which plug set: (fit feet below ground surface, <br /> Method oAo Z�0. , ) 2 &4-5 C�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 sheet. <br /> e. CONVERSION XQ A NAM WELL <br /> State Engincees Permit No.: (attach copy of permit) <br /> County Where Well is Located: <br /> Water Well Use: <br /> C. MUTNOD OE RECC 4M11�T,1 DRILL N F DISTURBANCE: <br /> __— 0 4 _ <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 operatoes Representative: c4mies V.Muedwff Title: Vice President <br /> Signature of Operstoes Representative: Date: <br /> -U;%minWtarcNhwpect3n8 FomisUM Abandonmcnt t'inst Rpt.doc <br />