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2 <br />Complete One (1) of Either Subsections A S A; and Subsection C. <br />A. 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 />Oealed Dole: <br />Meat Cement Grout, top to Bottom: grout mixture used: <br />1)pe 1 -2 Cement, 1.5 bags cement per 100' drill hole volume <br />FINeat Cement Grout, interval grouting: grout mixture used: <br />Intervals grouted (feet beneath ground surface, method and materials): <br />❑Abandonment Fluid Mixture (Such as Sodium Dentonite with Polymer) Brand Name:. <br />Marsh Funnel viscosity of abandonment fluid: <br />Type of surface plugging used: _ <br />Depth at which plug set: feet below ground surface, <br />Method: <br />QXia <br />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.: <br />County Where Well is Located: <br />Water Well Usc; <br />(attach copy of permit) <br />C. rviETIIOD OV RFC�I.AlN -II (G DRtI -,I. SIZE DIE$_TLTRl3ANCE: <br />The Operator who conducted the prospecting drill operation states that the information set forth hereupon is true: to the <br />hest of their knowledge. <br />Name of Operator's Representative: <br />Signature of Operators 42epre�� ntstivc: , –� Date: <br />41: mrin shureV'raspectn�g rdmisV)H AlumJortmeut Final Rpt doc <br />