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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(a)_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 WCi tto—Z_6 <br /> Individual/Company responsible for plugging and sealing the well: <br /> Name(s) God s e T c+l b.,, .LLC_ <br /> Mailing Address n(, Z gC 2 bl�i• Wd. <br /> City, St.,Zip <br /> Phone(area code& no.)97C-27.S/758 Email: a0 •e- <br /> o� <br /> Well (Hole) Owner: , <br /> NAME(S) �� CL [`�al�2(t�to5 Phone(include area code) <br /> Mailing Address, City, St.,Zi k R00 A 'T PRX 4- <br /> ACTUAL WELL LOCATION: County <br /> Property Address, City, St,Zip CD- 25121'Z <br /> 1/4 of the 1/4, Sec. ,Twp. 0 N. or Cl S., Range ❑ E. or it W., P.M. <br /> Distance from Section Lines Ft.from F7 N. or S., Ft. from r7jE. or E] 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 12 171 or zone 13 F]; Units must be meters; Datum must be NAD83; Unit must be set to true north. <br /> Easting o yC3. g Northing /a2 .2- 9 7J�s • � <br /> I (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) k�� LQ�►b!` Con_,, �,kQ, <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 /> !!�G from 3 feet to 1/,2 V feet <br /> 101b C"LN QX-VA C Q A from C 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 /> �ac)�L 4-1�1 �4 e/Z 9 Mo <br /> It is th res ity of the caner to have the well/hole properly ugged and sealed. The Well Construction Contractor <br /> is responsible fo the owner of this reauirement. <br />