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2 <br />Complete One (I) of Either Subsections A or B; and Subsection C. <br />A. PERMANENT ABANDONMENT (Check the appropriate box and provide information) <br />5 &lugged dry hole, method of plugging:& e Pratt a1/77/v & C 4, 3 7b <br />0.)/771/A) of SeRP/X6 - , ?tfa2IT ?WO r— o pWc -O✓= iW <br />Depth at which cowxete-plug set: L/ G I <br />?o4'/ c4n9 <br />Sealed Hole: <br />[1Neat Cement Grout, top to bottom: grout mixture used: <br />feet below ground surface. <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: - %OPSO /.. • <br />Depth at which plug set: feet below ground surface, <br />Method: PO L" r-0g <br />sec. <br />Z "Jther 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: MD beiLL w ' peem <br />Lust CIO f/loLE'Gv1.S W LC 8'7e CciiIc)GtS Ev 27 s,4.) b-z5 d i wcz-z5 ek <br />4/s rclee 6420er4 cv 4AOS nloo 7745V SeRAIS.EZ � ;mac <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: /44-& Q ZdahR Title:040AW &m &A j 4 " <br />Signature of Operator's Representative: <br />vl: min\share`J'rospecting Forms'i)FI Abandonment Final Rpt.doc <br />Date: 45/11 <br />