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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(cDstate.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 -23 <br /> Individual/Company responsible for plugging and sealing the well: <br /> Name(s) God_% t7Y.t,\%r. LA.0- <br /> Mailing Address t Z_goZ vj'� .- <br /> City, St., Zip fv'o"�Mn Q,, W. $ILA oj <br /> Phone (area code& no.)910•Z15- I"159 Email: o�oi - Cot-- <br /> Well (Hole) Owner: <br /> NAME(S) Z W4At.a\AF -' Phone(include area code)OkOL- LALk6--y1819 <br /> Mailing Address, City, St.,Zip�Jv�� <br /> ACTUAL WELL LOCATION: County �ifllt�or`(1 <br /> Property Address, City, St,Zip LICZ NV}Nlj I�� gt 2 1 <br /> 1/4 of the 1/4, Sec. ,Twp. I 171 N. or ❑ S., Range 0 E. or El W., P.M. <br /> Distance from Section Lines Ft.from I7 N. or[_ S., Ft. from 0E. 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 1f3 F]; Units must be meters; Datum must be NAD83; Unit must be set to true north. <br /> Easting,�0 � 96 `/ . / �Northing y 1 F 7'{. <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 /> 0/The well was not in use and was plugged and sealed.l� <br /> El Other(please explain)QA�LNLAAOf� r CDO-L &6 <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 /> 50\10 3/e VRD q'60u ' x 2 a av rw from feet to feet <br /> go C,,�,�-4 µ�x�,3 �1 pew from feet to 5 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 nam If signing print name&title Date (mm/dd/yyyyy) <br /> a f�3v f/ef <br /> It is the responsibility of th w ner to have the well/h a properly plugged and sealed. The Well Construction Contractor <br /> is responsible for notifvina the owner of this reauirement. <br />