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2 <br />Complete One (1) of Either Subsections A or B; and Subsection C. <br />A. PEILVIANENT 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 />RIScaled Hole: <br />FV 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 />❑?ther 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.: (attach copy of permit) <br />County Where Well is Located: <br />Water Well Use: <br />C. METIIOD OF RF'( l,..UMINC DRIIN,i. SITE ISTURBAINCE: <br />The Operator who conducted the prospecting drill operation state that the infor ruction set forth hereupon is true to the <br />best of their knowledge. <br />r~ Name of Operator's Representative:. j1l -tle: _- - <br />Signature of Operrt&s ltepresuntative: �" Date. <br />1�: minLshffe Ymcpeceing Fornts!t)ff ANLIWOMMIlt Futai Rpr.doc <br />