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<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) 4 <br />s <br />Plugged dry hole method of lu in : Ho\t f \le t, ?\.sh ' <br />p gg g K4,11., SwefA _ .1 -400 -1---_ <br />o,P CaNr 6' ??wE?,'? tw w?l??-E R??t^R i°144R gT? NL??r- A)?o ZND!?ovlL,oF 1. ZS ?n <br />Depth at which concrete plug set: n feet below ground surface. <br />?Sealed Hole: <br />F 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: <br />Type of surface plugging used: <br />Depth at which plug set: <br />Method: <br />B. CONVERSION TO A WATER WELL <br />sec. <br />W?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 />State Engineer's Permit No.: <br />feet below ground surface, <br />(attach copy of permit) <br />County Where Well is Located: <br />Water. Well Use: <br />C. M1ET. OI1.OF RECLAIMING DRI.L,L SITE DISTURBANCE: - S%';E So.... S3_TL-,,-, 1ZE4ZAbZJb Pw*b <br />_,. SEE E ..._w..?S ._.....?I?+. c..R No'S, 1k-20oB -23" -o 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 />1?(i?s?'Qt rtt" <br />Name of Operator's Representative: __?N?AR,. W. S?v?r t'lo N? Title: Sc?+y?o?v Co,r X. EaSPMNJ% eS, <br />Signature of Operator's Representative:._ _ Date:. ?, S t o <br />M:\min?shareTmspecting Forms`011 Abandonment Final Rpt.doc