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<br />G <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 />Sealed Hole: <br />u Cement Grout, top to bottom: <br />C - NQ ; 'tx_\w4 D $roorn SN&tACC 3y w-)i-5-t k-A!k -0646& GATE 'tjw m <br />FINeat 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: <br />Type of surface plugging used: <br />Depth at which plug set: <br />Method: <br />feet below ground surface. <br />k 3LpS3 <br />grout mixture used: W ET Ce! mrmr ? SfAr?t !N <br />feet below ground surface, <br />sec. <br />V?ther 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.: <br />County Where Well is Located: <br />Water. Well Ilse: <br />(attach copy of permit) <br />C. MET. .OD.QF REC1A1M1Nf; DRILL SITE DI'STURBAItiiC"F.; .. S,`TC ??--_13r ?E C?itAi?t*D ?)n?X? <br />Z..._..........._._-...._.._..._....---- <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: , Ai?-k wy _S ?AK?oN Title: Sc.?a1?a C?? Cs? o S?K?? ? LfS , Lt e <br />Signature of Operator's Representative: . Sate:. 1n ?Vs <br />nA: mW,ihareAF'rospeeting FormsOl I Abandonment Final Rpt.doc