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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 VgG7 Ito-?-S <br /> Individual/Company responsible for plugging and sealing the well: <br /> Name(s) <br /> Mailing Address &12-007— <br /> city, St.,zip 1hor,4-rzz,s e., 6 . l311 <br /> Phone (area code& no.) Cl�G-2�S- i7 Email:Well (Hole)(Hole) Owner: rA <br /> NAME(S) Phone(include area code)9�Z�y��D <br /> Mailing Address, City, St.,Zip �� �. l3ep t 5 t) k CPvot�w �3 3 2 <br /> ACTUAL WELL LOCATION: County Ci2a�Zx�n <br /> Property Address, City, St, Zip L"DZ \It�"2U �ta. cAr�on c. NCO. gtZt2 <br /> 1/4 of the 1/4, Sec. ,Twp. 171 N. or ❑ S., Range El E.or 0 W., P.M. <br /> Distance from Section Lines Ft. from I7 N. or S., Ft. from C]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 M or zone 1311n; Units must be meters; Datum must be NAD83; Unit must be set to true north. <br /> Easting C� �' �' Northing 2- <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) r- c r CVa'Q,V"plQ. <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 /> �0�b 3�B (f co1w +y�vc lC �1�� R ¢d�g�t,1A 2a,� from _feet to feet <br /> i-" c`� A c'1gdQ,1 from U 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 /> r 8`3d �G <br /> It is the responsibility of the well owner to have the well/hole proper) plugged and sealed. The Well Construction Contractor <br /> is racnnncihla for nntifvinn the nwner of this reauirement. <br />