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2 <br />Complete One (1) of Either Subsections A or B; and Subsection C. <br />A. <br />PERMANENT ABANDONMENT (Check the appropriate box and provide information) <br />1 ) Plugged dry hole, method of plugging: <br />Depth at which concrete plug set: <br />W Sealed Hole: <br />feet below ground surface. <br />( ) Neat Cement Grout, top to bottom: grout mixture used: <br />B. <br />(X) Neat Cement Grout, interval grouting: grout mixture used: J0 <br />f er <br />t I i <br />nl <br />4J Of " :,L-C Qj LAP-"' <br />Intervals grouted (feet beneath ground surface, method and materials): Joaor.l fo <br />. <br />?v+i «ItV4 )?tc1?i :"a .L+_ 1 <br />?,•S? 4 v?j ?2 ?? tJ -? <br />r ot? , y e Y <br />36 <br />ca) <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 />( ) Other 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 />CONVERSION TO A WATER WELL <br />State Engineer's Permit No.: <br />County Where Well is Located: <br />Water Well Use: <br />C. METHOD OF RECLAIMING 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 />T <br />Name of Operator's Representative: R aq' Title: `L <br />r <br />Signature of Operator's Representative: Date: 0 <br />Wrni&share`•Prospecting Furors\DH Abandonment Final Rpt.doc <br />(attach copy of permit)