Laserfiche WebLink
rR LA) Daoc� <br /> 2 <br /> Complete Office(1)of Either Subsections A or B;and Subsection C. <br /> A. PERMANENT ARAM-DONMM(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 /> ( )'filed Hole: <br /> ( )Ned Cement Grout,top to bottom: grout mixture used: <br /> ( j Neat Cement Grout,interval grouting: grout mixture used: <br /> Intervals grouted(feet beneath ground surface,method and materials): <br /> (y}Abandonment Fluid Mixture(Such as Sodium Bentonite with Polymer)Brand Name: 40xt+IP <br /> a <br /> Marsh Funnel viscosity of abandonment fluid: L[{" see. <br /> Type of surface plugging used: Ce eti 1 <br /> t <br /> Depth at which plug set:_� feet below ground surface, <br /> ( j 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 /> B. CONy afON TO A WATER WELYj <br /> State Engineer's Permit No.: (attach copy of permit) <br /> County Where Well is Located: <br /> Water Well Use: <br /> C. MEMOR QE REC�A"G DRILL sl(TE n][STyafz$A_r10E: _ <br /> The Operator who conducted the prospecting drilf operation states that the information set forth hereupon is true to the <br /> best of their knowledge. <br /> Name of-Operatoes Representative: Charles V.Muefioff _ Title: Vice President <br /> Signature of Operator's Representative:_ _ Date: <br /> •'M;%minWwedImspecting FunusUM Aban ion ncnt Find Rpt.doc <br />