2013-11-14_GENERAL DOCUMENTS - C1992080

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Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only ,;WS -09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 4/2012 (303) 866 -3581 Fax (303) 866 -3589 dwruermksonline(&- 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 bladc or blue ink. Instructions and plugging standards are on reverse side of form. Well Permit Number of the well being plugged 20%scps or MH File Number MH- Hole ID #Name l2t b Individual/Company responsible for pluanina and sealing the well: Name(s) C S Mailing Address 1 G O city, st, zip 'DVIi AN60 I CtA o FJ�L j 61301 Phone (area code & no.) M 305' 4 1 Z Email: Well (Hole) Owner: NAME(S) Q&1CRMGtL 1- =14kAZ -y} I tVC_ Phone (include area code) 940 gz 4:7:7Z Mailing Address, City, St, Zip ACTUAL WELL LOCATION: County . L-k'PLAMPt Property Address, City, St, Zip v��A SE 1/4 of theme 1/4, sec. 33. Twp. N. or ❑ S., Range _9 ®E. or JM W., n) {� P.M. Distance from Section Lines &40 Ft. from n N. or Ir S., 5'80_ Ft from MfE. or ❑ W. Line. Subdivision Name 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 12n or zone 13 fl; Units must be meters: Datum must be NAD83; Unit must be set to true north. Easting Northing I (we) report the existing well (hole) was plugged and sealed on the date of 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) The well was plugged with the following materials placed at the indicated intervals: Amount and Type of Material tt Method of Placement Interval � �� hGe� O Y �tmL ✓G l-.e_ 1444vtj _ 2 Ae 4$ AG N 4- from JO feet to O feet from feet to feet from feet to feet Intervals of casing removed/ripped in feet from -- feet to O 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 or enter full name If signing print name & tide Date (mm/dd/yyyyy) L- ----Q- �--� ,� ��. C l jc,�►v�c� l�� . l 1-7 -� 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.