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9 <br />Complete One (1) of Either Subsections A or B; and Subsection C. <br />A. PER:ti1ANENT ABANDONMENT (Check the appropriate box and provide information) <br />Plugged dry hole. method of plugging: <br />Depth at which concrete plug set: <br />Sealed Hole: <br />Neat Cement Grout, top to bottom <br />feet below ground surface. <br />grout mixture used: <br />FINeat Cement Grout, interval grouting: grout mixture used: <br />Intervals grouted (feet beneath ground surface, method and materials): <br />✓1 Abandonment Fluid Mixture (Such as Sodium Bentonite with Polymer) Brand Name: <br />Abantonite (Baroid), 15% solids sodium montmorillonite grout <br />Marsh Funnel viscosity of abandonment fluid: _ —_60 <br />Type of surface plugging used: Type 1 -2 Cement <br />Depth at which plug set: 10 —_ feet below ground surface, <br />Method: Pump Abantonite grout from bottom of hole up to top <br />sec. <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.: <br />County Where Well is I- ocated: <br />Water Well Use: <br />C. ;METHOD OF RECLAIMING DRILL. SITE DISTURBANCE: <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 Representative: Joshua Tiner Title: Supervisor <br />Signature cif Operator's Representative: _ V Date <br />M_ min.share'l'rospecting Fomis`l)It Abandonment Final Kpt doc <br />