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Complete One(1)of Either Subsections A or B;and Subsection C. <br /> A. PEILNIANENT ABANDONMENT(Check the appropriate box and provide information) <br /> �Plued d hole method f plugging: to h � C 0,kAr)�� l�ti���� � ►� <br /> gg dry P gin g; �� S`r <br /> 0 1 - CiC k <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 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 /> Match 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 /> FVO er 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: _ <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: n ela_M. Bellantoni y Title:_consultant <br /> Signature of Operator's Representative: ___ 0,t o U-bq- Date: ,_._November 21, 2018 <br />