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Form No. <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />For Office Use Only <br />GWS-09 <br />1313 Sherman St.. Ste 821, Denver, C080203 <br />I <br />10/2011 <br />(303) 866 -3581 Fax (303) 866 -3589 h= ;Uwww.water.state.co.us <br />WELL ABANDONMENT REPORT <br />Use to report plugging and sealing of permitted wells, monitoring and other holes. Type or <br />print in black or blue ink Instructions and plugging standards are on reverse side of form. <br />Well Permit Number of the well being plugged_ c� 1 S 7 6— F or <br />MH File Number MH- Hole ID XName A+ Cr -S t,a i tort ti}e )12 <br />Individual/Company Individual/Company responsible for Plugging and sealing the <br />swell: { <br />NAME(S) N g i " c i C+� V 1+11n.�ae I. 1—G <br />tclQiyti <br />,tpM <br />Mailing Address Peg b 001..1 Ke v q W 630 <br />City, St., Zip 4 CAP- C 0 9 109- O 6 C7 <br />Phone (fit)) Z-76 <br />WeN Mole) Owner. <br />NAME(S) r- h c V lm— Phone ( ) <br />Mailing Address, City, SL, Zip <br />n <br />ACTUAL WELL LOCATION: County <br />Property Address, City, St, Zap g t (,Mel <br />1114 of the 1/4, Sec I D �_ S.; �arge �. E3 . or W., P.M. <br />Distance from Section Lines 6 00 Ft From [Jf N. or ❑ S., 3 ;100 Ft From ❑ E. or VW. 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 0 orzone 13 ❑; Units must be meters; Datum must be NAD83; Unit must beset to true north. <br />Easdng Northing <br />} <br />I (we) report the existing well (hole) was plugged and sealed on the date of for the following reason(s): <br />e well was plugged and sealed as required under Well Permit Number <br />Z <br />Th e well was not in use and was plugged and sealed. <br />❑ Other (please explain) <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 />C-1 0.L► A% V, — H 3-, 3 <br />0 L&%P a ce from y feet to t b feet <br />O C-ow, - <br />"A(!' from feet to feet <br />from feet to feet <br />Intervals of casing removedfripped in feet from feet to S feet <br />Report must be signed by person who performed the well plugging work or by the well owner if this person is unknown or not reachable. I <br />(we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge. <br />Signature <br />Please print the Signers Name & Title <br />Date <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 />