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Page 3 of 3 <br /> Marsh Frmnel viscosity of ahandamment fluid: see. <br /> Type of surface ping used: <br /> Depth at which plug set F <br /> feet below ground surface, <br /> Method: <br /> 0 2d.Other method used with approval of the Division of Reclamation,Mining and Safety,describe in detail <br /> method and materials used on a separaft 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 /> V. METHOD OF RECLAIMING DRILL SITE SURFACE DISTURBANCE: <br /> needed. Any Tracks <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 Hoe berg consdting Geolo ist/Mana er <br /> (Name o or's Rep ve) (Title) <br /> _' <br /> (Signature of Operato epres tative) (Date) <br />