2013-06-10_REPORT - P2011010

• Permit No: P2011010
• IBM Index Class Name: REPORT
• Doc Date: 6/10/2013
• Doc Name: ANNUAL FEE/REPORT
• From: OPERATOR
• To: DRMS
• Email Name: RCO
• Media Type: D
• Archive: No

2
Complete One (1) of Either Subsections A or B; and Subsection C.
A.
PERMANENT ABANDONXIENT (Check the appropriate box and provide information)
Plugged dry hale. method of plugging: _
.Depth at which concrete plug set: -.w_ feet below ground surface.
Sealed Bole:
F-,/]Neat Cement Grout, top to bottom: grout mixture used:
Type 1 -2 Cement, 1.5 bags cement per 100' drill hole volume
❑Ncat Cement Grout, interval grouting: grout mixture used:
Intervals grouted (feet beneath ground surface, method and materials):
Abandonment Fluid Mixture (Such as Sodium Bentonite with Polymer) Brand Name:
Marsh Funnel viscosity of abandonment fluid: T, sec.
Type of surface plugging used.
Depth at which plug set:_ feet below ground surface,
Method:
�Jther method used with approval of the Division of Reclamation, Mining and Safety; describe in
detail method and materials used on a separate attached sheet.
B. CONVERSION TO A WATER WEI.
State Engineer's Permit No.:
County Where Well is Located:
Water Well Use:
(attach copy of permit)
C. METHOD OF RFCL,AINII4`G DR IA. S)TE IIIST[TRBANCE;
The Opc7ator who conducted Mlle prospecting drill operation states that the information set forth hereupon is true to the
best of their knowledge.
Name of Operator's Representative- s-
Signature of Operators P.cprr.5entatdve: __. . � hate;
i�f',minitiharetProspecUng Fornts`. H AINindonment Final Rpt.doc;