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Page 3 of 3 <br /> Type of surface plugging used: <br /> Depth at which plug set: feet below ground surface, <br /> Method: <br /> 2d. Other method used with approval of the Division of Reclamation,Mining and Safety; describe in detail <br /> 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 /> V. METHOD OF RECLAIMING DRILL SITE SURFACE DISTURBANCE: <br /> Drill hole collar and mud pit backfilled, compacted, and graded within drill pad to pre-drilling <br /> contours. No re-vegetation performed, as drilling was performed in an existing disturbed area. <br /> I i <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 /> Richard Petersen == I Mine Foreman ---� <br /> (Name of Operator's Representative) (Title) <br /> (Signature of Operator's Representative) (Date) <br />