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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 /> F71Plugged dry hole,method f plugging: .�(�� G(�iJv�(� �k' t liv���f 1 '') <br /> i 1, o a (�c:�t� <br /> Depth at which concrete plug set: f 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 /> 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 RECLAIMING DRILL SITE DISTU"ANCE: <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 y 'title: Consultant <br /> Silmature of Operator`s Representative: _ _ ,S` ' .�_ �. Date: ,Xgvember 20,2018 <br /> M:Vnin�chare\Prospecting Forms%Dff Abandonment Final Rpt.doc <br />