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Complete One (t) of Either Subsections A gt B; and Subsection C. <br />A. PERMANENT ABANDONMENT (Check the appropriate box and provide information) <br />ā¯‘Plugged dry hole, method of plugging: <br />Depth at which concrete plug set: feet below ground surface. <br />Sealed 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 />[]Neat Cement Grout, interval grouting: gout mixture used: <br />Intervals grouted (feet beneath ground surface, method and materials):_ <br />Abandonment Fluid Mixture (Such as Sodium. Bcntonite 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 />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.: _ (attach copy of permit) <br />County Where Well is Located: <br />Water Well Use: <br />C. METHOD OF Rl?(,LAfi1VIi3NG DRILL. SITE E DISTURBANCE: <br />The Operator who conducted the prospecting drill operation states that the information set forth hereupon is tnle to the <br />best of their knowledge. <br />Name of Operator's Repre.wntativc:.,gp, -. __h6n444-- Title: <br />Sign: atvreofOperatgesReptesertative: Date: <br />K-iniiAshamTrmpecting Fomukl)H Abandonment 81141 Rpt.doc <br />