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<br />i <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 />7Plugged dry hole, method of plugging: lk?\E ?, ?_\ D tip „? S.IZ F a « <br />rh,2bS3 Oc- LrMCM-T ?E?lyrR<1? 3? ?„?1j?q-t ??VtSZ A66;S2EGNT?S Q? <br />Depth at which concrete plug set: 10 feet below ground surface. McExtR , to <br />?Sealed Hole: <br />FINeat Cement Grout, top to bottom: grout mixture used: <br />RNeat 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 />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 />8. 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. IM ET OD OF RECLAIMING I}RI.I,L SITE DISTURI ANI"F,: 5 <br />TtI-a <br />Refl. _ <br />w.__f! to fl ___._ .S E Et?E A_...._...W.!. ?!'.!'i.._,_..? A. ?.Pl?c.? l?p _.....,M._L_X_...'? ? ?IL,....,.. N_° I _'_}._.._.X..' .Z?s? ?1.....-._2.?.?.w ?..?._ ?_..._.__.._..._ _._.__ <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 />?i 2e s,AeNr, <br />Name of Operator's Representative: _ M A czx w . S ?,? ?v? o N Title: S« ??o N Co gL ro se Rv, ct s , ??c . <br />Signature of Operator's Representative: -N\N 031- ? , s L-X ---- Date:._..._ N Q <br />_.__................... ..... ........__...? .............. ...... .._.. _?. _. _........_......._.. __ <br />tvl:?mintsharelPrnspectin FormAN I Abandonment Final Rpt.doc