Laserfiche WebLink
<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 />( ) 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 />Marsh Funnel viscosity of abandonment fluid: sec. <br />Type of surface plugging used: <br />Depth at which plug set: feet below ground surface, <br />Method: <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.: (attach copy of permit) <br />County Where Well is Located: <br />Water Well Use: <br />METHOD OF RECLAIMING DRILL SITE DISTURBANCE: <br />C. <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 />Signature of Operator's Representative: <br />Title: <br />Date: <br />Wmin\share\Prospecting Forms\DH Abandonment Final Rpt.doc