Laserfiche WebLink
Complete One(1)of Either Subsections A or B;and Subsection C. <br /> A. PE%N. IANENT ABANDONMENT(Check the appropriate box and provide information) <br /> Plugged dry hole,method of plugging; r )�- 0 a A-e::JE l L ���� <br /> Depth at which concrete plug set: - d fe elow 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 /> R�ther 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 REC:LAIMIN'G DRILL SITE DIST RBAN ,E: <br /> The Operator%vho 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: atA%u Date: November 20_,1018 <br /> W,minlshareTrospecting FormsU)14 Abandonment Final Ritt.doc <br />