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2 <br />Complete One (1) of Either Subsections A or B; and Subsection C. <br />A. <br />B. <br />PERMANENT ABANDONMENT (Check the appropriate box and provide information) <br />❑Plugged dry hole, method of plugging: <br />Depth at which concrete plug set: feet below ground surface. <br />❑Sealed Hole: <br />1-1 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: sec. <br />Type of surface plugging used: <br />Depth at which plug set: feet below ground surface, <br />Method: <br />Rther 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 />CONVERSION TO A WATER WELL <br />State Engineer's Permit No.: _ <br />County Where Well is Located: <br />Water Well Use: <br />METHOD OF RECLAIMING DRII-,L SITE DISTURBANCE: <br />(attach copy of permit) <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: <br />Signature of Operator's Representative; <br />Wmin'shareTrospecting Forms`,Dl l Abandonment Final Rpt.doc <br />Title: <br />- bate: <br />