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Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office use only <br />GWS -09 821 Ce ftmiai Bldg., 1313 Shannon St, Denver, CO 80203 <br />412012 (303) 8®6.3581 Fax (303) 8664569 dwraermitsonuneAstate.co.us <br />WELL ABANDONMENT REPORT <br />Use to repot pkWfrlp and sealing of perrn0 a waft, morlNaft and odd holes. This form can be <br />computer pensraled. typed or primed in bleck or blue kk Inieue ne and pirgpirp slandards are on <br />reverse aide of fam. <br />Well Permit Number of the well beMg OkWed N 7A or <br />MH File Number MH- Hole 1D*/Name <br />reso alAe far chionino and seahna the well: <br />Name(s). 4-71W-40-3 <br />McNV Address / dO /-7441 dr/ A6 4 T .ed, <br />City, st, Zip e'ee&,1.c/ AiTx <br />Phone (area code & no.69) did -G w7 tom: <br />WON (Hole) owner: <br />NAME(S) nuc STT t:- S Phone (kvaude area codeU/71 q� z 6 9 -o �� J <br />Mang Addre% My, St, zip A d. &,t 4Z h1p,9 cn/cc <br />ACTUAL WELL r nrAUM County. A-'Zr- A ,a <br />Property Address, City, St, Zip <br />/tT. 1/4 of thelV d 1 M, Sea J_L Twp. , aD 11N. or Or S., Range ®E 'W. <br />or j . l Z7& P.M. <br />Distance from Section Unes //_ 3�6 Ft from W N. or C S., 19Q2 Ft from ❑E or JNW. Line. <br />Subdivision Name Lot____. Block____, FikrptInit <br />Optioned: GPS weN location information in UTM format. You must dreck GPS unit for required seew as follows: <br />Format must be UTM, zone 12 rl or zone 13 04; Units must be meters; Datum must be NAD83; Unit must be ad to true north. <br />%stlng & Y 614.2 Nordit <br />I (we) report the eods M wall (hole) was plugged and sealed on the date of for the following r saeort(s): <br />❑ The well vas pkrgged and sealed as required under Well Permit Number <br />OR The well was not in use and was plugged and sealed. <br />0 Otlter (per fin) <br />The well was pkgW with the foli wing malerials placed at the indicated intervals: <br />Amount andps of Material Med od of Plat»an" krliervai <br />7—z 2 .✓ ` �N �`r�r� from _ 176 feet tD _ =�Q feet <br />Pa 1410Q from 90 feet to 13 test <br />Jed a Vc.1 from 13 feet to 2 feet <br />Intervals of caeft .".I. amippsd In fist from _Q_ fess to 2__ teat <br />Report MW be Signed or name atter ed by person who parbmred the wall plugging work or by the well owner tf this person Is unknown or <br />not readnabW I (ws) have read the statements made herein, know the contents thereof, and that they are trus to my (our) knowledge. <br />Sign or enter full nerve If signing print nerne & title Data (mrn/cid/yyyyy) <br />jo Wa/ mooar— /�, //Z e /1 i a — <br />k Is the fowl iGly of the wal owner to haus ftwaMlole propedy plugged and sealed. The Wel Constnac hon Contractor <br />is responaibie for nodfAV the owner of this requirement. <br />