2013-09-16_GENERAL DOCUMENTS - C2010089

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Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only GWS -09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 4/2012 (303) 866 -3581 Fax (303) 866 -3589 dwrpermitsonIine(c , state. co us WELL ABANDONMENT REPORT Use to report plugging and sealing of permitted wells, monitoring and other holes. This form can be computer generated, typed or printed in black or blue ink. Instructions and plugging standards are on reverse side of form. Well Permit Number of the well being plugged 77131 or MH File Number MH- Hole ID # /Name DW12 -1 Individual /Company responsible for plugging and sealing the well: Name(s) Western Fuels Colorado, LLC Mailing Address PO BOX 33424 City, St., Zip Denver, CO. 80233 Phone (area code & no.) 303 255 -5800 Email: Well (Hole) Owner: NAME(S) Westen Fuels Colorado, LLC Phone (include area code) 303 255 5800 Mailing Address, City, St., Zip PO BOX 33424, Denver, Colorado, 80233 ACTUAL WELL LOCATION: County Montrose Property Address, City, St, Zip SW 1/4 of theme 1/4, Sec. 25 , Twp. 47 N. or ❑ S., Range 16 ❑ E. or E] W., New Mexico P.M. Distance from Section Lines 480.6 Ft. from n N. or n S., 392.1 Ft. from —I E. or 0 W. Line. Subdivision Name New Horizon North Mine Lot Block , Filing /Unit Optional: GPS well location information in UTM format. You must check GPS unit for required settings as follows: Format must be UTM, zone 12 ' 1 or zone 13 n ; Units must be meters; Datum must be NAD83; Unit must beset to true north. Easting Northing I (we) report the existing well (hole) was plugged and sealed on the date of 08122/2013 for the following reason(s): ❑ The well was plugged and sealed as required under Well Permit Number ❑ The well was not in use and was plugged and sealed. ® Other (please explain) Well DW12 -1 (Permit # 77131) was dry and was therefore plugged and abandoned The well was plugged with the following materials placed at the indicated intervals: Amount and Type of Material Method of Placement Interval 6.5 inch hole, 13 bags of bentonite chips pour from surface from 19.5 feet to 70.5 feet 10 in csg, 10 sks Portland I I, w /6gals H2O /sk pour from surface from 2.5 feet to 19.5 feet from feet to feet Intervals of casing removed /ripped in feet from 0 feet to 2.5 feet Report must be signed or name entered by person who performed the well plugging work or by the well owner if this person is unknown or not reachable. I (we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge. Sign enter full name If igning print name & title Date (mm /dd /yyyyy) C� e�_r4k kn , C) * fire, w� /v es l T,v ,pis k", r.Jo 19 0 L b 0 !3 It is the responsibility of the well owner to have the well /hole properly plugged and sealed. The Well Construction Contractor is responsible for notifying the owner of this requirement.