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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: 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 />bAM/D M-AND SODI&M heNTONIT6 0MUT <br />Marsh Funnel viscosity of abandonment fluid. } sec. <br />Type of surface plugging used: d- t/ 1 L U F <br />Depth at which plug set: ? feet below ground surface, <br />Method: 6, P AA1ROL?(pl?.6 LC PI.}?f SI AMelt PLUG IKSZ:AL <br />( } 0 010 1A <br />r ethod used with approvul 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.: N A (attach copy of permit) <br />County Where Well is Located: N A <br />Water Well Use: <br />C ;METHOD OF U.&LAIMING DRILL SITE DISTURBANCE: BACK(la-_ P <br />Atqh <br />.0 ISM S --AT-4-A <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. ??? f <br />Name of Operator's Representative: ?a 'T Lc C I7 DGP Title: ?° fit- <br />11 <br />Signature- of Operator's Represertrativ _ Date: / 0 <br />M!minA%hareV'ro*Wing Fm n%Dff Abandonment Final Rpt.doc