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Attachment D <br />2 <br />Complete One (I) of Either Subsections A or B; and Subsection C. <br />A. PERM&NEN'T ARANDONMENT (Check the appropriate box and provide information) <br />( ) Plugged dry hole, method of plugging: <br />Depth at which concrete plug set: <br />(X) Sealed Hole: <br />feet below ground surface. <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 />RADID BAND ?5Qbl!JM BeNToNiT(4- rp"4j ' <br />Marsh Funnel viscosity of abandonment fluid: }' ql? sec. <br />Type of surface plugging used: e4 1Y1eN F <br />Depth at which plug set- .3 -.1.3 feet below ground surface, <br />Method: _?RDLIT ? Af. T ?2? a?Jc.C P ? . S"Ma PLUG jgS r AL <br />o c . <br />h?onl?N0 a <br />{ ) er method used with approval ofa Division of Reclammtion, 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: A <br />C. METHOD OF RECLAIMING DRILL SI DISI RBANCE: SACK ED P?T?-__ <br />At4b <br />D IS T,D_RR.L&s_ TA Tom. <br />The Operator who conducted the prospecting drill operation states that the inforn3ation set forth hereupon is true to the <br />best of their knowledge. <br />Name of Operator's Representative: -?Dah T? <br />! J C o.DP Title: <br />Signature of Operator's Representativ - Date: 6115/0.1 <br />ivt +min;5haceV'nrspxting For=OH Abandonment Final Rpt.doc