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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@state.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 W67 llo - Z-7 <br /> Individual/Company responsible for plugging and sealing the well: <br /> Name(s) C7"d 3a... <br /> Mailing Addresipi 0L <br /> City, St.,Zip ftr-4WSZ, 14 C) 7j <br /> Phone(area code& no.)91G"275-9758 Email: <br /> Well (Hole) Owner: <br /> NAME(S) 2¢,DV-L!►fZ Phone(include area code)90z-QL4(o-y\QR <br /> Mailing Address, City, St.,Zip5_v, 300 } i� N Crary P,a 3 3r12 <br /> ACTUAL WELL LOCATION: CountytL4R �� <br /> Property Address, City, St, Zip gD1_UW�Q , ��n <br /> 1/4 of the 1/4, Sec. ,Twp. F] N. or ❑ S., Range El E. or 0 W., P.M. <br /> Distance from Section Lines Ft. from 17 N. or I S., Ft. from ❑E. 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 I`7 or zone 13 F]; Units must be meters; Datum must be NAD83; Unit must be set to true north. <br /> Easting 3 0 5 5 ?Lt Lf,-7 Northing L e: -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 /> ❑ The well was not in use and was plugged and sealed. <br /> Other(please explain) Q, �fxL>I}�o/� crop-2 `a <br /> The well was plugged with the following materials placed at the indicated intervals: <br /> Amount and Type of Material Method of Placement _Interval <br /> from feet to a i�_feet <br /> ctr) carrol-�A A CAPV Q.C� from feet to 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 /> 42 <br /> It is the r sibility e I owner to have the well/hole proper ged and sealed. The Well Construction Contractor <br /> is responsible for notifvinq the owner of this requirement. <br />