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Form No. <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />For Office Use Only <br />GWS -09 <br />821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />4/2012 <br />(303) 866 -3581 Fax (303) 866 -3589 dwmermitsonline(M- state.co.us <br />WELL ABANDONMENT REPORT <br />Use to report plugging and sealing of permitted wells, monitoring and other holes. This form can be <br />computer generated, typed or printed in black or blue ink Instructions and plugging standards are on <br />reverse side of form. <br />Well Permit Number of the vlmll being plugged 43(013 F or <br />MH File Number MH- Hole ID #/Name 10 D <br />Individual/Company responsible for pluaaina and sealing the well: <br />Name(s) <br />Mailing Address 2n6l Y/( W&j 160 <br />City, St., zip MUP- 4w-4t> . Cc�o t�A, 813ot <br />Phone (area code & no.) M 381541/2 Email: <br />Well (Hole) Owner. <br />NAME(S) Phone (include area code) 940 3ZZ 4? ?'Z <br />Mailing Address, City, St, Zip 4413 B W <br />ACTUAL WELL LOCATION: County 4.A PLATA <br />Property Address, City, St, Zip N/A <br />N15- _1/4 of theme 1/4, Sec. 25, Twp. X%?. IN N. or D S., Range —9_ ® E. or X W., N M P.M. <br />Distance from Section Lines 2240 Ft. from r j N. or K S., 1030 Ft from NE. or ❑ W. Line. <br />Subdivision Name Lot . Block . Filing/Unit <br />Optional: GPS well location information in UTM format. You must check GPS unit for required settings as follows: <br />Format must be UTM, zone 12 f'1 or zone 13 l 1; Units must be meters; Datum must be NAD83; Unit must beset to true north. <br />EasUng Northing <br />I (we) report the existing well (hole) was plugged and sealed on the date of for the following reason(s): <br />❑ The well was plugged and sealed as required under Well Permit Number <br />fiC The well was not in use and was plugged and sealed. <br />E3 Other (please e)plain) <br />The well was plugged with the following materials placed at the indicated intervals: <br />Amount and Type of Material Method of Placement Interval <br />t!S $U i'% 60.5 t'e0 ^CVe -1 -e— ?k64e A to from /,/ D feet to feet <br />from feet to feet <br />from feet to feet <br />Intervals of casing removediripped in feet from feet to feet <br />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 <br />not reachable. I (we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge. <br />Sign or enter full name <br />If signing print name & title <br />Date (mm /dd/yyyyy) <br />L-7 13 <br />It is the responsibility of the well owner to have the well/hole properly plugged and sealed. The Well Construction Contractor <br />is responsible for notifying the owner of this requirement. <br />