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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 dwrpermitsonlinel-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 <br /> Individual/Company responsible for plugging and sealing the well: <br /> Name(s) Gc96 j ai1j jK LLC <br /> Mailing Address <br /> City,St.,Zip <br /> Phone(area code&no. 910)011q-17548 Email: 1�9�k'Q ao 1, ee.n <br /> Well(Hole) Owner: / <br /> NAME(S) Z�P��I P— ^e k� Phone(include area codeI�) <br /> Mailing Address, City, St.,Zip v.e \3 JA�0a IR S9 U � SA-) n 0 Y i k �3 z <br /> ACTUAL WELL LOCATION: County <br /> Property Address, City,St,Zip <br /> 1/4 of the 1/4,Sec. ,Twp. ®N. or 13 S., Range ® E.or ® W., P.M. <br /> Distance from Section Lines Ft.from rl N.or 0 S., Ft.from ®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 12 171 or zone 13i Ell; Units must <br /> ttabe meters; Datum must be NAD83;Unit must be set to true north. <br /> Easting 0 ��2. 3 /Northing oZ 8,2 ­2 U /® F <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) D aaymon Coa.ej tg <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 Ib 3fe (nod fll x 2 hucll�'e.d .� wMX7 from_ feet to feet <br /> so 16 cad'i ow (A%Xsd nr4 ce►ppod. from_�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. 1 (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 /> It is the r pPility of the a ner to have the well/hole properly gged and sealed. The Well Construction Contractor <br /> is respo notifying t e owner of this requirement. <br />