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Attachment D <br />2 <br />Complete One (1) of Either Subsections A or B; and Subsection C. <br />A. PERMANENT ABANDONMENT (Check the appropriate box and provide information) <br />( ) Plugged dry hole, method of plugging: <br />Depth at which concrete plug set: <br />N 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 />(}Q Abandonment Fluid Mixture (Such as Sodium Bentonite with Polymer) Brand Name: $ar,al 41 <br />c20% Solis Qvirck -Irv r-- <br />Marsh Funnel viscosity of abandonment fluid: <br />Type of surface plugging used: t?tnen <br />Depth at which plug set: 3 -13 feet below ground surface, <br />Method: po u red. 6--wN en f. 7'r--e.w+ m i" a y 1 etc G r oo <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 />8. CONVERSION TO A WATER WELL <br />State Engineer's Permit No.: <br />County Where Well is Located: <br />Water Well Use: <br />(attach copy of permit) <br />C. METHOD OF RECLAIl? ING DRILL SITE ?ISTURBANI gA: r; 1l;?p/ f S w ¢ rc <br />baAckP, lk?! uj +k r,na4,er,'aj b?tie0.iI. feesell. ?Tersoi1 wil( 6g. <br />adl +?e. Rrl fi IA culfl'i'W anpt Qpp retied .seed m? X °?P lted Burr" , <br />5P P --L Q <br />L) P4rr-o w, pf an.+:v3 5ea56vl. <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: <br />OAK Tsc tl or? <br />Signature of Operator's Representative: -? T <br />7 q0 sec. <br />Title: 6C0 L° 4:L ST <br />Date: j o/ 110 q <br />M:knin\tihamTmspecting rorms`J)H Abandonment Final RptAm