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E <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 />❑Plugged dry hole, method of plugging: <br />B. <br />Depth at which concrete plug set: feet below ground surface. <br />Sealed Hole: <br />Neat Cement Grout, top to bottom: grout mixture used: <br />Type 1 -2 Cement, 1.5 bags cement per 100' drill hole volume <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 />DD.ther method used with approval of the Division of Reclamation, Mining and Safety; describe in <br />. 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 />C. METHOD OF RECLAIMING DRILL SITE DISTURBANCE: <br />(attach copy of permit) <br />'Me 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: _ Joshu a � - - -Tiner Supervisor - <br />Signature of Operator's Representatia-v <br />------- ...... Date: <br />M .minlsharc %prospecting Fomisll)1( Abandonment finai Kpt doe <br />