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Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only <br /> GWS-09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br /> 4/2012 (303) 866-3581 dwrpermitsonline(Dstate.co.us <br /> WELL ABANDONMENT REPORT <br /> Use to report plugging and sealing of permitted wells,monitoring and other holes. This form can be <br /> computer generated,typed or printed in black or blue ink. Instructions and plugging standards are on <br /> reverse side of form. <br /> Well Permit Number of the well being plugged or <br /> MH File Number MH- Hole ID #/Name C - 8 <br /> Individual/CompanV responsible for plugging and sealing the well: <br /> Name(s) 6',15v �I, LDDC <br /> Mailing Address 'ZBo Z b /M I'c� <br /> city, St., zip Nv g&e 25e. , Co- A '!�3 <br /> Phone (area code& Email: - <br /> Well (Hole) Owner: <br /> NAME(S)`Z-v� bl 4(L N nQtt -3 Phone(include area code) `'I'02-ya(0-ylE9 <br /> Mailing Address, City, St.,Zip 5U► �iQQ I IT4U as (!J �1P�i X C Wade 3J 3N2 <br /> ACTUAL WELL LOCATION: County CrR uyt&p" <br /> Property Address, City, St,Zip l4C7Z`IA\kaw?-A. �ovn 6,1 k l.t I CID. g 1 7-1Z <br /> 1/4 of the 1/4, Sec. , Twp. R N. or ❑ S., Range El E. or 0 W., P.M. <br /> Distance from Section Lines Ft. from r7 N. or S., Ft. from �`jE. or ❑ W. 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 M or zone 13 I]; Units must be meters; Datum must be NAD83; Unit must be set to true north. <br /> Easting -3 0 S 5- V 9,.2 Northing 42 O )--9 3/, 3 <br /> 1 (we) report the existing well (hole)was plugged and sealed on the date of for the following reason(s): <br /> ❑ The well was plugged and sealed as required under Well Permit Number <br /> ❑�` ther <br /> he well was not in use and was plugged and sealed.(please explain) F o c\ cor0. 0- <br /> The well was plugged with the following materials placed at the indicated intervals: <br /> Amount and Type of Material � 4 `M`etthhod of Placement _Interval <br /> 51 k10 31B "O`,C a1C7 x 2 �ac ycH & N)w1`.o QA from feet to C�} feet <br /> �O 1b CQM(LAA* N k')NA d- CA Dx2aA from C) feet to J feet <br /> from feet to feet <br /> Intervals of casing removed/ripped in feet from feet to feet <br /> 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 <br /> not reachable. I (we) have read the statements made herein, know the contents 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 /> It is the responsibility he well owner to have the well/hole properly ged and sealed. The Well Construction Contractor <br /> is responsible for notifying the owner of this requirement. <br />