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Complete One (1) of Either Subsections A Qr B; and Subsection C. <br />A. PERMANENT ABAND0NMENT (Check the appropriate box and provide information) <br />❑Plugged dry hole, method of plugging: <br />Depth at which concrete plug set: _ W feet below pound surface. <br />Oealed 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 />ONeat Cement Grout, interval pouting: grout mixture used: <br />Intervals grouted (feet beneath ground surface, method and materials): <br />FAbandonment 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 />Method: <br />sec. <br />other 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 WELT, <br />State Engineers Permit No.: <br />County Where Well is Located: <br />Water Well Use; <br />C. Mt ETHOD OP RE("L,A,LNIIi' G DRHsL I;rE I)ISTIR)$;atiC:E: <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 Represcut:ttivc: 6—__J?-L-} 1�6 Title: <br />ilmaturc of Operator's i~ ept t:.,entative: <br />M:tminy%Mar Wr(xtpft-ting PorMS4)F1 Abandonment final Kptdoc <br />