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I <br />2 <br />Complete One (1) of Either Subsections A or B; and Subsection C. <br />A. PERMANENT ABANDONMENT (Check the appr <br />?Plugged dry hole, ethod of plugging: ). f 1 <br />pro?i informatil?a) Va ?3 <br />S' 7?'j t4 t <br />Depth at which concrete plug set: feet below ground surface. <br />?Seated 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: <br />Type of surface plugging used: <br />Depth at which plug set: feet below ground surface, <br />sec. <br />Method: <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 />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 />C. METHOD OF RECLAIMING DRILL SITE DISTURBANCE: .......S?Tr- ZU E_ X'U-,4ttA' ,L-& -A"'M'b <br />Sctv b, CD vS+n? (zoVD rn ?~1G ?7L. Nom X-2.co$ -2,3a - Z. <br />. <br />---- __...._............._._..__ . _.._._._._._._...._........_........._ ................... .?_._..._ -._ _..._...._..._.............M..__...._...._....._.......... ...... ._._....._._....--_ <br />The Operator who conducted <br />best of their knowledge. <br />Name of Operator's Representative: <br />on states that the information set forth hereupon is true to the <br />Signature of Operator's Representative: <br />Title:c! <br />Date:._..._.__...-._ __._....._........_............_- <br />M:tmin\-,harelf'rospecting Forms'JA I Abandonment Final Rpt.doc