Spreadsheet: 08b11e3c-0170-4466-8461-22e8b7357282
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | STATE OF NEVADA | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12 | Unnamed: 13 | Unnamed: 14 | Unnamed: 15 | Unnamed: 16 | Unnamed: 17 | Unnamed: 18 | Unnamed: 19 | Unnamed: 20 | Unnamed: 21 | Unnamed: 22 | Unnamed: 23 | Unnamed: 24 | OFFICE USE ONLY | Unnamed: 26 | Unnamed: 27 | Unnamed: 28 | Unnamed: 29 | Unnamed: 30 | Unnamed: 31 | Unnamed: 32 | Unnamed: 33 | Unnamed: 34 | Unnamed: 35 | Unnamed: 36 | Unnamed: 37 | Unnamed: 38 | Unnamed: 39 | Unnamed: 40 | Unnamed: 41 | Unnamed: 42
 |  |  |  |  |  |  |  | DIVISION OF WATER RESOURCES |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Log No. |  |  |  |  |  |  |  |  |  |  |  |  | 1/4 | Section | Township | Range | Counties
 |  |  |  |  |  |  |  | WELL DRILLER'S PLUGGING REPORT |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Permit No. |  |  |  |  |  |  |  |  |  |  |  |  | NW | 1 | 47N | 18H | Carson City
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Basin |  |  |  |  |  |  |  |  |  |  |  |  | NE | 2 | 46N | 18 | Churchill
PRINT OR TYPE ONLY |  |  |  |  |  |  |  | Please complete this form in its entirety in |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | SW | 3 | 45HN | 19 | [NAME]
DO NOT WRITE ON BACK |  |  |  |  |  |  |  | accordance with NRS 534.170 and NAC 534.340 |  |  |  |  |  |  |  |  |  |  |  |  |  | NOTICE OF INTENT NO. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | SE | 4 | 45N | 20 | [NAME]
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | WELL NAME (If applicable): |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 5 | 44N | 21 | Elko
1 | OWNER |  |  |  |  |  |  |  |  |  |  |  |  |  | ADDRESS AT WELL LOCATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 6 | 43N | 22 | Esmeralda
MAILING ADDRESS |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 7 | 42N | 23 | [NAME]
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Subdivision Name: |  |  |  |  |  |  |  |  |  |  |  |  | County: |  |  |  |  |  |  |  |  |  |  | 8 | 41HN | 23H | Humboldt
2 | [NAME] |  |  | [NAME] |  |  | [NAME] |  | T |  | N/S R |  |  | E | Latitude |  |  |  |  |  |  |  |  | UTM E |  |  |  |  |  |  |  |  |  | NAD 27 |  |  |  |  | 9 | 41N | 24 | Lander
PERMIT/WAIVER No. |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Longitude |  |  |  |  |  |  |  |  | N |  |  |  |  |  |  |  |  |  | NAD 83/WGS 84 |  |  |  |  | 10 | 40HN | 24H | Lincoln
Issued by Water Resources |  |  |  |  |  |  |  |  | Parcel No. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 11 | 40N | 25 | Lyon
3 | TYPE OF WELL |  |  |  |  |  |  |  |  |  |  |  | Is this well being plugged because a |  |  |  |  |  |  |  |  |  |  | Is there an existing well log? |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 12 | 39HN | 26 | Mineral
 | Domestic |  |  |  |  |  | Irrigation |  |  |  | Test |  | replacement well was drilled? |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 13 | 39N | 26H | Nye
 | Municipal/Industrial |  |  |  |  |  | Monitor |  |  |  | Stock |  | If yes, what is replacement well NOI? |  |  |  |  |  |  |  |  |  |  | If yes, what is NDWR well log #? |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 14 | 38N | 27 | Pershing
4 | EXISTING WELL CONSTRUCTION |  |  |  |  |  |  |  |  |  |  |  |  | 7 | WELL PLUGGING PROCEDURE |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 15 | 37N | 28 | [NAME]
Depth Drilled |  |  |  |  |  | Feet |  | Depth Cased |  |  |  |  | Feet | Was well cleaned out to total depth? |  |  |  |  |  |  |  |  |  | yes |  | no |  |  |  |  |  |  |  |  |  |  |  |  | 16 | 36N | 29 | Washoe
EXISTING CASING SCHEDULE |  |  |  |  |  |  |  |  |  |  |  |  |  | If well was not cleaned out to total depth, please explain why: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 17 | 35HN | 30 | White Pine
Size O.D. |  | Weight/Ft. |  |  |  | Wall Thickness |  |  | From |  |  | To |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 18 | 35N | 31
(Inches) |  | (Pounds) |  |  |  | (Inches) |  |  | (Feet) |  |  | (Feet) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 19 | 34N | 32
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 20 | 33HN | 33
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Was the well contaminated? |  |  |  |  |  |  |  | yes |  |  | no |  |  |  |  |  |  |  |  |  |  |  |  |  | 21 | 33N | 34
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Was the casing pulled? |  |  |  |  |  |  | yes |  | no | If pulled from: |  |  |  |  |  |  |  | feet to |  |  | feet |  |  |  | 22 | 32HN | 35
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Was the casing over drilled? |  |  |  |  |  |  |  | yes |  |  | no |  |  |  |  |  |  |  |  |  |  |  |  |  | 23 | 32N | 36
Existing Perforations: |  |  |  |  |  |  |  |  |  |  |  |  |  | If casing was left in place, please show where additional perforations were made: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 24 | 31N | 37HN
 |  | Type of perforation |  |  |  |  |  |  |  |  |  |  |  | Additional Perforations: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 25 | 30N | 37
 |  | Size of perforation |  |  |  |  |  |  |  |  |  |  |  | Type of perforater used: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 26 | 29N | 38
From |  |  |  |  |  |  | feet to |  |  |  |  | feet |  | From |  |  |  | feet to |  |  |  |  | feet |  | Number of perfs per linear foot |  |  |  |  |  |  |  |  |  |  |  |  |  | 27 | 28N | 39
From |  |  |  |  |  |  | feet to |  |  |  |  | feet |  | From |  |  |  | feet to |  |  |  |  | feet |  | Number of perfs per linear foot |  |  |  |  |  |  |  |  |  |  |  |  |  | 28 | 27N | 40
From |  |  |  |  |  |  | feet to |  |  |  |  | feet |  | From |  |  |  | feet to |  |  |  |  | feet |  | Number of perfs per linear foot |  |  |  |  |  |  |  |  |  |  |  |  |  | 29 | 26N | 41
From |  |  |  |  |  |  | feet to |  |  |  |  | feet |  | From |  |  |  | feet to |  |  |  |  | feet |  | Number of perfs per linear foot |  |  |  |  |  |  |  |  |  |  |  |  |  | 30 | 25N | 42
From |  |  |  |  |  |  | feet to |  |  |  |  | feet |  | From |  |  |  | feet to |  |  |  |  | feet |  | Number of perfs per linear foot |  |  |  |  |  |  |  |  |  |  |  |  |  | 31 | 24N | 43
5 | WATER LEVEL |  |  |  |  |  |  |  |  |  |  |  |  | From |  |  |  | feet to |  |  |  |  | feet |  | Number of perfs per linear foot |  |  |  |  |  |  |  |  |  |  |  |  |  | 32 | 23HN | 44
Static water level |  |  |  |  |  |  |  | feet below land surface |  |  |  |  |  | From |  |  |  | feet to |  |  |  |  | feet |  | Number of perfs per linear foot |  |  |  |  |  |  |  |  |  |  |  |  |  | 33 | 23N | 44H
Artesian flow |  |  |  |  |  |  |  | [NAME] |  |  |  |  | P.S.I | From |  |  |  | feet to |  |  |  |  | feet |  | Number of perfs per linear foot |  |  |  |  |  |  |  |  |  |  |  |  |  | 34 | 22N | 45
Water temperature |  |  |  |  |  |  |  | º F | Quality |  |  |  |  | From |  |  |  | feet to |  |  |  |  | feet |  | Number of perfs per linear foot |  |  |  |  |  |  |  |  |  |  |  |  |  | 35 | 21HN | 45H
6 | Additional Notes or Comments |  |  |  |  |  |  |  |  |  |  |  |  | From |  |  |  | feet to |  |  |  |  | feet |  | Number of perfs per linear foot |  |  |  |  |  |  |  |  |  |  |  |  |  | 36 | 21N | 46
 |  |  |  |  |  |  |  |  |  |  |  |  |  | From |  |  |  | feet to |  |  |  |  | feet |  | Number of perfs per linear foot |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 20HN | 46H
 |  |  |  |  |  |  |  |  |  |  |  |  |  | From |  |  |  | feet to |  |  |  |  | feet |  | Number of perfs per linear foot |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 20N | 47
 |  |  |  |  |  |  |  |  |  |  |  |  |  | 8 | WELL PLUGGING MATERIALS |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 19N | 47H
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Material Used |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 18HN | 48
 |  |  |  |  |  |  |  |  |  |  |  |  |  | From |  |  |  | feet to |  |  |  |  | feet |  |  |  |  |  |  |  |  |  | Pumped | Poured |  |  |  |  |  | 18N | 49
 |  |  |  |  |  |  |  |  |  |  |  |  |  | From |  |  |  | feet to |  |  |  |  | feet |  |  |  |  |  |  |  |  |  | Pumped | Poured |  |  |  |  |  | 17N | 49H
 |  |  |  |  |  |  |  |  |  |  |  |  |  | From |  |  |  | feet to |  |  |  |  | feet |  |  |  |  |  |  |  |  |  | Pumped | Poured |  |  |  |  |  | 16N | 50
 |  |  |  |  |  |  |  |  |  |  |  |  |  | From |  |  |  | feet to |  |  |  |  | feet |  |  |  |  |  |  |  |  |  | Pumped | Poured |  |  |  |  |  | 15N | 51
 |  |  |  |  |  |  |  |  |  |  |  |  |  | From |  |  |  | feet to |  |  |  |  | feet |  |  |  |  |  |  |  |  |  | Pumped | Poured |  |  |  |  |  | 13HN | 52
 |  |  |  |  |  |  |  |  |  |  |  |  |  | From |  |  |  | feet to |  |  |  |  | feet |  |  |  |  |  |  |  |  |  | Pumped | Poured |  |  |  |  |  | 13N | 53
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Neat Cement Fluid Weight |  |  |  |  |  |  |  |  |  |  |  | lbs/gal |  |  |  |  |  |  |  |  |  |  |  |  |  | 12N | 54
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Bentonite Grout |  |  |  |  |  |  |  |  |  |  |  | % bentonite |  |  |  |  |  |  |  |  |  |  |  |  |  | 11N | 54H
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Date Started |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 10N | 55
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Date Completed |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 09N | 55H
 |  |  |  |  |  |  |  |  |  |  |  |  |  | 9 | DRILLER'S CERTIFICATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 08N | 56
 |  |  |  |  |  |  |  |  |  |  |  |  |  | This well was plugged and abandoned under my supervision and the report is true |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 07N | 57
 |  |  |  |  |  |  |  |  |  |  |  |  |  | to the best of my knowledge. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 06HN | 58
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Name |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 06N | 59
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Contractor |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 05N | 60
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Address |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 04N | 61
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Contractor |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 03HN | 62
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 03N | 63
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 02HN | 63H
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Nevada contractor's license number |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 02N | 64
 |  |  |  |  |  |  |  |  |  |  |  |  |  | issued by the State Contractor's Board |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 01N | 65
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Nevada driller's license number issued by the |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 01S | 66
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Division of Water Resources, the on-site driller |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 02S | 67
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Signed |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 03S | 68
 |  |  |  |  |  |  |  |  |  |  |  |  |  | By driller performing actual drilling on site or contractor |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 04S | 69
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Date |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 05S | 70
(Rev. 12-13) |  | USE ADDITIONAL SHEETS IF NECESSARY |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | pg. |  | of pg. |  |  |  |  |  |  | 06S | 71
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 07S
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