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Form No. <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />For Office Use Only <br />GWS-OI <br />821 Ceritennial Bldg., 1313 Shennen St; Denver, CO 80203 <br />4/2012 <br />(303) 88"W1 Fax (303) 866.3589 &ierrnitsonG e�cr�us <br />WELL ABANDONVIEW REPORT <br />Use to report pkryyirry and seamy of p a Me d wells. mtorraairp all other how. This brm can be <br />conami yerreriAsd, typed or 1 P - in black or bkn i* bv&ucdtons and pke icy afardards are on <br />reverse side of form. <br />web Pm* Number of the whaN bekv ptuped 4 or <br />MH Fite Number MH- Hole IDoff IM" MZ11 —levy <br />4mm*ridWCornoeuw resconslNe for oluaabha OW aealina ft Well: <br />Name(s). 41hf*F-3 i•�/� <br />Ma&g Address 6 no ��fit/ rx/ Aa�� : Q� <br />City, St. Zip L.r i �I & efld Al <br />Phone (area code S no.6 9) d 1G -G *V7 sTwi: <br />Well (Hole) Owner: <br />NAws) Fur-a4 U /k-uLL S 69a L. Phone (include area code) (7�9') -0 601 <br />Maung Address, City, St, Zip -4, d. de,r 4;19 F/a 1 en/cc <br />ACTUAL WELL LQCAMN: County. 2L wrd +✓ 1 <br />Property Address. Cly. St, Zug <br />A1/4 of th:(d 1/4, Sea. _& Twp. M?a__ ❑ N. or A S., Range _ ® E or Iff W.. l Tff P.M. <br />Distance from Section Lanes A Ft from rl N. or Pr S., 1A Ft from 13Eor JOW. tine. <br />Subdivision Name lot . Block . Fiing/thhtt <br />Optional: (PS well location a>bnnation In UTM format. You must check GPS unit for required ssow as kNows: <br />Format must be UTM. zone 12 it or zone 13 JIQ ; Units must be meters; Datum must be NAD83; Uric must be set to true north. <br />Eastlng d yQ S'R!VL Noudit 6j!393044 <br />I (we) report the existing well (hole) was plugged and sealed on the date of for the following reason(s): <br />❑ The wall was pkgged and sealed as required under Well Permit Number <br />J( The well was not in use and was pkgged and seeded. <br />13 Other (Please w0ain) <br />The well whes pkgged wph the following materials placed at the indicted w arvals: <br />Amount and Type of IN - I Method of Plsosmsnt Interval <br />(�� rc u/i Pur9.oc c� from z?S y faet to -?-?g teat <br />L S ,1U � p ALI from �/ _ feet to feet <br />4.G o" a o-17-�u �f.0 c d/ from _(,� feet to feet <br />intervals of Comm ....reo ipped In feet from �_ feet to ' feet <br />Report MUM be signed or name entered by person who performed the well pkuWV work or by the well owner It this person is unknown or <br />not reachable. i (we) have read the staleawds made herein, know the cordes thereof and that they are true to my (as) <br />Sign or enter fiA name <br />M signing print name & tide <br />Dale (mmidd/yyyyy) <br />7,—Wo/ M4)04Zr /&i /e•c <br />I/ o <br />ft E ft . esp0t A ift, Of the Wd OMTN to he* fit@ WA?Ide properly Ougged and Sealed. The Wtr "abon Conhacbor <br />is reepor>e�le for not8yft the owner of this requkement <br />