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Form No. STATE CW COLORADO, OFFICE OF THE STATE ENDER Far Office Usu: 0* <br />GWS -09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />4/2012 (303) SW3581 Fax (303) WS -3589 dwrDermitsonline0state.co.us <br />WELL ABANDONMENT REPORT <br />use to report pkrggirg and aeallrg of penrdMed wells, nwr►sakw and other hobs. This Form can be <br />computer generated, typed or primo m black or blue ink bv*uctkm and pkrggvV standards are on <br />reverse side of form. <br />well Permit Ntnnber of the wtl u bektg P� - dt?q7R.3 or <br />MH Flit Number MH- Hie ID #ane _M "J <br />InrPwirir al/Conmany reKam ble for oluadna and sealing the well: <br />Name(s) &eAV 140 [lN//"' 'i%/l• ce✓^t <br />Mailing Address 6W lowkm/ �i dC C A i <br />City, St, Zip /�T _A&AL <br />Phone (area code & no.) ?l� '�2'L•TGSYTEmail: <br />Wen (Hole) Owner. <br />NAME(S)=�-j"J/ f-AfzL!f 1,00e Phone (include area code)(7i e-4 -a �-,'O j <br />Mailing Address, City, St, Zap A D. /fie A 1S9 ��aLt.✓GL �% . �/o�%�G <br />ACTUAL WELL LOCATION: County ia/l <br />Property Address, City, St, Zip <br />11/1/4 of the,�fd 1/4, Sea _, Twp. _,2V O N. or CK S., Range d-, ® E. or A W., _ P.M. <br />Distance from Section Unes Ft. from n N. or pr S., U% Ft from QE. or JVW. line. <br />Subdivision Name Lot . Block . FilirgUnit <br />Oplionai: GPS well location information in UTM format You must check GPS unit for required settings as Follows: <br />Format must be UTM, zone 12 n or zone 13 r1; Units must be meters; Datum must be NAD83; Unit must beset to true north. <br />Ened" Nou MeV <br />I (we) report the existing well (hole) was plugged and sealed on the date of for the following reason(s): <br />0The well was plugged and seaksd as required under Well Permit Number <br />*The well was not in use and was plugged and sealed. <br />D Other (please w0ain) <br />The well was pl ggW with the Following materials planed at the indicated intervals: <br />Amount and Type of Mabrlai Medved of Placement Interval <br />14 -,,YrA//dirt d� from /.S b Fewto 130 feet <br />r A .—* Xj / i /du.K.4c d from,_ Feet to feet <br />/1 y -i t, -j / /!/d! from _ Feet to �_ feet <br />Intervals of casing rornovedliripped lin f" From Feet to Feet <br />Report mud be signed or name entered by person who per%rmed the well plugging work or by the well owner if this person is unitn6wn or <br />not reachable. I (we) have read the statements made herein, know the oonW is thereof, and that they are true to my (our) knowledge. <br />Sign or enter full name If signing print name & title Date (mm/dd/yyyyy) <br />responsibility of the well awner W have the weWhole properly plugged and seated. The Wd Construction Conttactor <br />is responsible for notifying the owner of this requirement. <br />