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Complete One (1) of Either Subsections A or B; and Subsection C. <br />A. PERMANENT ABANDONMENT (Check the appropriate box and provide information) <br />VPlugged 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: sec. <br />Type of surface plugging used: <br />Depth at which plug set: feet below ground surface, <br />Method: <br />E]hher 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 RECLAIMING DRILL SITE DISTURBANCF,: <br />The_only_reclamation..needed for each drill hole was the backfillin of said hole. No <br />additional 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: Ben Langenfeld <br />'title: Consulting Engineer <br />� <br />Signature of Operator's Representative: Date: <br />4 <br />Wmin`shamTruspecting Fonns`.DFI Abandunmcnt Final Kpt.doc <br />