Laserfiche WebLink
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 GEC fto-2 <br /> Individual/CompanV responsible for plugging and sealing the well: <br /> Name(s) Go�A2��. <br /> Mailing Address Co200Z rUlnlrti F,�. <br /> City, St., Zip Sa, x Co. 8Ia,03 <br /> Phone (area code& no.) Email c-o ,cof --- <br /> Well (Hole) Owner: <br /> NAME(S) Phone(include area code) 9VZ-gLX(0-yt S9 <br /> NJ <br /> Swk�l�,1g59 �azWA�S•Ic, FIAIc�'ex DNS <br /> Mailing Address, City, St.,Zip 'AN <br /> ACTUAL WELL LOCATION: County FYI 4c <br /> Property Address, City, St, Zip 402 \1 A� Q, Cv�nurN c� i �sl'LlZ <br /> 1/4 of the 1/4, Sec. ,Twp. I'-1 N. or El S., Range L❑ E. or 0 W., P.M. <br /> Distance from Section Lines Ft.from [7 N. or F— S., Ft. from OE. or n 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 M; Units must be meters; Datum must be NAD83; Unit must be set to true north. <br /> Easting Northing <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) <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 /> 501 b 3 h��mA d ?Q"cd from feet to a,;�-9 feet <br /> CW alo co, n^"'ceA aL CM?V9,-A from 'D 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 /> hle <br /> h• <br /> It is th po bill e well owner to have the well/hole properly plugged and sealed. The Well Construction Contractor <br /> is resn(r(sS <br /> 1 e for notifvina the owner of this requirement. <br />