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Attachment D <br />2 <br />Complete One (1) of Either Subsections A or B; and Subsection C. <br />A. PERM&NENT 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 />RAO D $kANO SO1) 1// M BjcNTON/T? <br />Marsh Funnel viscosity of abandonment fluid: 9o Sec. <br />Type of surface plugging used: a Ae-K T' <br />Depth at which plug set: .3 -14 feet below ground surface, <br />Method: G/QDUT PulnP?4 T RpL1 Cpl O?fkC Pl?L . SgTAe t PLg6 [N?'JL <br />OthRer? lh ?3UPW I <br />{ } method used with approval O% <br />e 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: N A <br />Water Wen Use: IV q. -- <br />c METHOD OF RECLAIMING IIRILL 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 />Name of Operator's Representative: ?Gt h ! J C II pp Title: _ IrO /a <br />Signature of Operator's Reprewntativ - Date: 06 <br />M.%min;xh=Vkospacting FormsW Abandonment Final Rpt.doc