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2 <br />Complete One (1) of Either Subsections A or B; and Subsection C. <br />A. PERMANENT ARANDONIMENT (Check the appropriate box and provide information) <br />Plugged dry hole, method of plugging:.__ „_„___ <br />B. <br />C. <br />Depth at which concrete plug set: feet below ground surface. <br />zSeaied 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 />D-t%at 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 abandormwnt fluid: <br />Type of surlace plugging used: <br />Depth at which plug set: feet below ground surface, <br />Method: <br />sec. <br />113ther 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 />CONVERSION TO A WATER W'ELI. <br />State Engineer's Permit No.: <br />County Where Well is Located: <br />Water Well Use: <br />(attach copy of permit) <br />METHOD OP RE( -LAI'� Ii N °G DRILL �1TE DISTURBANCE: __.____..._... <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: <br />sibmature of Operator's Representative: _ _ -_ . , Datti: 7Z24-7.0 <br />M:=minVharcTrosperting foMO))r AhandOmnem Gina! Rpt.doc <br />