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F4 <br />Complete One (1) of Eithur Subsections A or B; and Subsection C. <br />A. <br />B. <br />C. <br />PERMANENT AIIANDONMENT (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 Hole: <br />❑Neat Cemcnt Grout, top to bottom: grout mixture used: _. <br />ONkat 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: <br />Depth at which plug set: ,_,_, feet below ground Surface, <br />sec. <br />Method: <br />A er method used with approval of the Division of Reclamation, Mining and Safety; describe in <br />etail method and materials used on a separate attached sheet. packer abandonment <br />COWERS[ON TO A WATER WELL <br />State Engineer's Permit No.: <br />County Where Well is Located: <br />Water Well Use: <br />(attach copy of permit) <br />MLTHODOF RR LAIMLNG IlltILL SiT�;�iS'iURBANCE: <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; * Titic: <br />- - -i e- - <br />Signature of Operator's Representative: _ -- _ Elate: _„-'� <br />b1:m:n1ihar6ProipectingForms` R Abandonment Fhwl RpWoc <br />