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Attachment D <br />2 <br />Complete Once (1) of Either Subsections A or B; and Subsection C. <br />A. PEP-MAN NT 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 />(X) Abandonment Fluid Mixture (Such as Sodium Bentonite with Polymer) Brand Name: <br />,W010 81,AN5 SODIUM heY ONIT14 0"14T <br />Marsh Funnel viscosity of abandorunent fluid: see. <br />Type of surface plugging used: (r E #1 t K <br />Depth at which plug set: -4 -1 I feet below ground surface, <br />Method: f /!?r O C Y I . J q AthhCL rLt-(Co 1 /Yb 1 FtC <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 />B. CONVERSION TO A WATER WELL <br />State Engineer's Permit No.: IV A (attach copy of permit) <br />County Where Well is Located: NA <br />Water Well Use: N A <br />C METHOD OF RFCL:AIMING DRILL SITE DISTURBANCE: Mr-K,4 I d-6D R_- <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 />Nam of Operator's Representative: ? a h ' C Title: 1r° /a 5 <br />Signature of Operatoes, Representativ - _ Date: 0 611 01 <br />WroieahareVkospwing FormADH Abandonment Final Rpt.dor