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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(&-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 W&--i I t.-3 <br /> Individual/Company responsible for plugging and sealing the well: <br /> Name(s) C'io4gow 't.%`k%^!6 k I C- <br /> Mailing Address �Z��0"2. <br /> City, St.,zip VXwAse+Cb. E3140 3 <br /> Phone(area code&no.)T11D-Z-15- -7'%Email: aON ca"L- <br /> Well(Hole) Owner. <br /> NAME(S)ZaR1^'L jq- W nw+.y'A% Phone(include area code)Cm?- <br /> Mailing Address, City,St.,Zip S.�4e '%-600' V <br /> ACTUAL WELL LOCATION: County <br /> Property Address, City, St,Zip L C)-Z \1IR `OVA CRt lon e r co. <br /> 1/4 of the 1/4,Sec. ,Twp. I3 N. or 0, S., Range i® E.or ® W., P.M. <br /> Distance from Section Lines Ft.from r.1 N.or Q 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 Gl or zone 13 Units must be meters;Datum must be NAD83; Unit must be set to true north. <br /> Fasting d 5 ?, 2 Northing <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. <br /> E!f Other(please explain) C*p 1D(Z-" o r-- C-"L g, kd t - <br /> t <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 /> ,52 kb Na C%-ksL )rt%A1 *¢_d IL "t'A from feet to feet <br /> MA xa,d from feet tom_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 /> L;2 FA <br /> It is th6res`ponsiQity1bf the well owner to have the well/hole properly plugged and sealed. The Well Construction Contractor <br /> is responsible for notifvinq the owner of this requirement. <br />