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Complete One(1)of Either Subsections A or B;and Subsection C. <br /> A. PERMANENT ABANDONMENT(Check the appropriate box and provide information) <br /> 21 Plug ed dry hole,method of plugging: \�\ tab 4y)r.r;UNV­, ( tei �1 <br /> r <br /> Depth at which concrete plug set: d --1 feet below ground surface. <br /> ❑Sealed Hole: <br /> Neat Cement 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 /> Abandonment Fluid Mixture(Such as Sodium Bentonite with Polymer)Brand Name: <br /> Marsh Funnel viscosity of abandonment fluid: sec. <br /> Type of surface plugging used: <br /> Depth at which plug set: feet below ground surface, <br /> Method: <br /> Rlather method used with approval of the Division of Reclamation,Mining and Safety;deseribe in <br /> detail method and materials used on a separate attached sheet. <br /> B. CONVERSION 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. METHOD OF RRCLAIM1NG DRILL SITE DISTURBANCE: <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: Angela M. Bellantoni Ph.D. _ Title: Consultant <br /> Signature of Operator's Representative: �_^",,A%��l.tw _ Date.. ,_-November 20, 2018 <br />