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Complete One (1) of Either Subsections A or B; and Subsection C. <br />A. <br />PERMANENT ABANDONMENT (Check the appropriate box and provide information) <br />Plugged dry hole, method of plugging: <br />Holes backfilled with cuttings to 7' below surface, 5' concrete plug poured on top <br />Depth at which concrete plug set: 2 feet below ground surface. <br />Sealed Hole: <br />Neat Cement Grout, top to bottom: grout mixture used: <br />Neat Cement Grout, interval grouting: grout mixture used: <br />Water Well Use: <br />2 <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: <br />Method: <br />feet below ground surface, <br />El Dther 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 />METHOD OF RECLAI.vIIrNC3 DRILL SITE DISTURBANCE: <br />Cuttings .,., pit backfilled, covered with topsoil and seeded. All equipment and unnatural <br />debris removed, entire area seeded and logs /brush strewn about area <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: Title: <br />perator's Representative: .._........._ -_- Date: <br />bttminlshare`}.'rospecting Fomis\OOH' Abandonment Rinat Rpt.doc <br />