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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 WCY-I1e-2 Z <br /> Individual/Company responsible for plugging and sealing the well: <br /> Name(s) �edga �rz,tl�r.� LlC <br /> Mailing Address 62eO2 L'�k/M - <br /> City, St.,Zip Al on4rcose- CO. 91403 <br /> Phone(area code& no.)91a-a75-/75G Email: °k owl •C-0'—-- <br /> Well (Hole) Owner: <br /> NAME(S) Phone(include area code) Cf02-QLt(D " q100t <br /> Mailing Address, City, St.,Zip 101,59 Ij N2- <br /> ACTUAL WELL LOCATION: County �CLazv�r� <br /> Property Address, City, St, Zip 1402\)ra\ke, 4R11• �WV\00- c-ril, cc)- 121 <br /> 1/4 of the 1/4, Sec. ,Twp. 0 N. or ❑ S., Range 0 E. or 171 W., P.M. <br /> Distance from Section Lines Ft. from f7 N. or i.- S., Ft. from r'jE. or M 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 1`7 or zone 13 C77; Units must be meters; Datum must be NAD83; Unit must be set to true north. <br /> Easting 30 5-5 51� 6 Northing 126 z Q 0• <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 /> CSJ/Other(please explain) INO[o, <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 /> 2 <br /> ' % 3 jg ho�°- ���� �. ) k k "�g;a 4 gun: c from feet to 17 feet <br /> tG�b from L_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 /> 0� "" <br /> risre <br /> the res onsi of well owner to have the well/hole properly plugged and sealed. The Well Construction Contractor <br /> sponsible fo n ing the owner of this requirement. <br />