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a <br />2 <br />Complete One (1) of Either Subsections A or B; and Subsection C. <br />A. PERMANENT ABANDONMENT (Check th N ppro to b x and rovide Iin?fgrmation Plugged dry ole, method of plug in t rn\ `c ?1 L <br />- - -- <br />Depth at which concrete plug set: feet below ground surface. <br />?Sealed Hole: <br />FINeat Cement Grout, top to bottom: grout mixture used: <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: feet below ground surface, <br />Method: <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 />B. CONVERSION TO A WATER WELL <br />State Engineer's Permit No.: <br />(attach copy of permit) <br />County Where Well is Located: <br />Water Well Use: <br />C. MET...O OF RECLAIMING DRILL SITE DI'STURRANCE: S <br />_ tcr, to._3t_....?-XC _ AA__``?...._..._ <br />ht4P -%FbC'D V61N4 .. t%4 CNtb MAY pE(L NoL X-Zooms- Z3v-L <br />The Operator who conducted <br />best of their knowledge. <br />Name of Operator's <br />Signature of {operator's Representative: <br />that the information set forth hereupon is true to the <br />Title: _ \?V?r?(? ?? ? YN N VV <br />13atc.._......_........._........_..._...__. <br />ivl: min%share\Prospecting Formslt>f i Abandonment Final