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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 />( ) Plugged dry hole, method of plugging: <br />Depth at which concrete plug set: feet below ground surface. <br />(X) Sealed Hole: <br />( ) Neat Cement Grout, top to bottom: grout mixture used: <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 />(X) 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. See Attachment 2 <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 />C. METHOD OF RECLAIMING DRILL SITE DIS'TtIRBANCE: Mud pit backfilled and <br />----- ------------ <br />cove_red..with available topsoil. Surface scratched and seeded with <br />... ....... ......... ._...... ......... ....... ........... _.. __.... <br />BLM......r.e.c.ommend_e..d.......,9...e e d._-,mixture.... ..............-See._.,At_t _........................ <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 Operator's Representative: _Michael G_Leidich Title: Manager - Lynx-Royal LLC <br />`O?ZZ p <br />Signature of Operator's Representative- <br />_._.... ??1 Date: <br />M:'unin share i'ros}xetinb Fomis\Dl I Abandonment Final Kpt.doc