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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 dwrpermitsonline(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 240323 or MH File Number MH- 40319 Hole ID # /Name MW -6 Individual /Company responsible for plugging and sealing the well: Name(s) Transit Mix of Pueblo Mailing Address 444 E Costilla St. City, St., Zip Colorado Springs, CO 80903 Phone (area code & no.) 719- 475 -0700 Email: Well (Hole) Owner: NAME(S) Transit Mix of Pueblo Phone (include area code) 719- 475 -0700 Mailing Address, City, St., Zip 444 E Costilla St, Colorado Springs, CO, 80903 ACTUAL WELL LOCATION: County Pueblo Property Address, City, St, Zip SE 1/4 of the NW 1/4, Sec. 34 , Twp. 20 13 N. or K S., Range 64 0 E. or ll W., 6th P.M. Distance from Section Lines 1520 Ft. from Ixi N. or L7_ S., 2063 Ft. from (3E. or H 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 12 0 or zone 13 H; 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. X Other (please explain) The well was located within mining area that has been mined through. The well no longer exists. The well was plugged with the following materials placed at the indicated intervals: Amount and Type of Material Method of Placement Interval NA NA from feet to feet NA NA from feet to feet NA NA from feet to feet Intervals of casing removed /ripped in feet from feet to 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 & title % ran s ii-- Date (mm /dd /yyyyy) V, P. S'cjle S n � 1'4dfhI 'X e, t: / Mark K I L) N L 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.