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t4 <br />Complete One (1) of Either Subsections A or B; and Subsection C. <br />A. PEILNIANENT ABANDONMENT (Check the appropriate box and provide information) <br />Plugged dry hole, method of plugging: <br />Backfilling using drill cuttings or like material from nearby Willow Creek Mine <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 />❑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: <br />Type of surface plugging used: <br />Depth at which plug set: <br />Method: <br />feet below ground surface, <br />sec. <br />❑ether 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 Located: <br />Water Well Use: <br />C. METHOD OF RECLAIMING DRILL SITE DISTURBANCE: <br />(attach copy of permit) <br />The only reclamation needed for each drill hole was the backfilling qf said hole. No <br />tion _ <br />addial disturbance was created besides drilling. <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 />Ben Langenfeld <br />Title: Consulting Engineer <br />Signature of Operator's Representative: _ Date: G6 <br />Wmin'share',.Prospecting Form ID14 Abandonment Final Rpt.doc <br />