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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 dwrpermitsonlinea-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 VJ C1 -Vo -35 <br /> Individual/Company responsible for plugging and sealing the well: <br /> Name(s) Lt0A64' bitil line LLC <br /> Mailing Address (01;'S02 0V11r+2 9a. <br /> City,St.,Zip M o+n}y cn a,, C-o• 81 L40 3 <br /> Phone(area code&no.)11d-2'15- 1155 Email: 1 1 A�Of C16 0& "I ca^ <br /> Well(Hole)Owner: <br /> NAME(S)KW�H(L wy�& I% Phone(include area code) ftZ-4yfo-41 84 <br /> Mailing Address,City,St.,Zip t e 63 <br /> ACTUAL WELL LOCATION: County_Fao mnfn-� Counky _ <br /> Property Address,City, St,Zip 4 DZ VA 119N IiQa , C nor C O. 9 al 2- <br /> 1/4 of the 1/4,Sec. ,Twp. ® N.or 0] S., Range 13 E.or 0 W., P.M. <br /> Distance from Section Lines Ft.from In N.or I3 S., Ft.from ®E. or Q W. Line. <br /> Subdivision Name Lot Block , Filing/Unit <br /> Optional:GPS well location information in UTM format. You must check G PS unit for required settings as follows: <br /> Format must be UTM, zone 12� or zone 13 H; Units must be meters; Datum must be NAD83;Unit must be set to true north. <br /> Easting 7 0 E �2 7Y3,1 Northing /� ��. 0�-�7 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) carol oaxxkAVn cjpfLjL Vtolo, <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 /> K J�� a •pv v.W QA from feet to feet <br /> 1 S <br /> 0 �b CQ,YrIQ.RT' M�x¢.c� � c w c�nQ.d 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. I (we)have read the statements made herein,know the contents thereof,and that they are true to my(our)knowledge. <br /> Sign full name If signing print name&title Date(mm/dd/yyyyy) <br /> It is the r onsibility o he owner to have the well/ho properly p ugged and sealed. The Well Construction Contractor <br /> is responsible for notif a owner of this reauirement. <br />