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2 <br /> Complete One(1)of Either Subsections A or B;and Subsection C. 1/ <br /> A. PER(ANENT ABANDONMENT(Check the appropriate box and provide information) (( JIn b rO </ <br /> ®Plugged dry hole,method of plugging: -Dry y p- �,\c4tkn-�-1� <br /> t 1C( e� rM- <br /> Depth at which concrete plug set: G +o )D feet below ground surface. Ja+uc C'z,';,e4 <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 /> Rther 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. CONVERSION TO A WATER WELL <br /> State Engineer's Permit No.: (attach copy of permit) <br /> County Where Well is Located: j <br /> Water Well Use: <br /> C. METHOD OF RECLAIMING 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 /> t <br /> Signature of O rator's Representative: ,_. O tA% Date: NQ_yembgr 2Q, 018 <br /> l <br /> M.,\mW-Share?t'rospecting Foms,Dll Ahandonment final itpt.doc <br />