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2 <br /> Complete One(1)of Either Subsections A or B; and Subsection C. <br /> A. PERMANENT ABANDONMENT(Check the appropriate box and provide information) <br /> PIrPlugged dry hole,method of plugging: <br /> Filled with drill cuttings, portland cement and dry earth <br /> Depth at which concrete plug set: 0-10 feet below ground surface. <br /> Sealed Hole: <br /> Neat Cement Grout,top to bottom: grout mixture used: <br /> 0-10 feet plugged with 3-80 lb bags of sack create. <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 /> Dther 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 /> ( METHOD OF RECLALMING 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 operators Representative: Angela M. Bellantoni Ph.D. Title: Consultant <br /> Signature of Operator's Representative: Q�tA% Date: December 10,2018 <br /> V lnintshare-3'rospecting Forms)H Abandonment Final€tpt.doc <br />