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Page 3 of 3 <br /> Marsh Funnel viscosity of abandonment fluid: sec. <br /> Type of surface plugging used: <br /> Depth at which phi'set: feet below ground surface, <br /> Method: <br /> El2d.Other method used with approval of the Division of Reclamation,Mining and Safety,describe in detail <br /> m and materials used on a separate attached sheet. <br /> B. CONVERSION TO A WATER WELL <br /> State Engineer's Permit No.: I I (attach copy of permit) <br /> County Where Well is Located: <br /> Water Well Use: <br /> V. METHOD OF RECLAIMING DRILL SITE SURFACE DISTURBANCE: <br /> 0 unt—ed Og was used. No pits of pads we Fe <br /> eded. Any Tracks on non e)dsting roads were graded <br /> and seeded with approved seed mix <br /> The Operator who conducted the prospecting drill operation states that the information set forth <br /> hereupon is true to the best of their knowledge. <br /> Harald Hoegberg wristAft Geoid istlMana er <br /> (Name o or`s Rep ve) (Title) <br /> F-- 111e� <br /> , Z Z <br /> (Signature of Operato ep tative) (Date) <br />