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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 fort. <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) 67zr-4fW' Dki 1/140 <br /> L-�11• <br /> Mailing Address to 2 p <br /> a0hteA. <br /> ' <br /> City,St.,Zip ri-(t10"sQ, Co- e AC)--6 <br /> Phone(area code&no.)T10 OR,5-17%Email: C 16e ac ( . cOr <br /> Well(Hole) Owner: <br /> NAME(S) Z 9 R Phone(include area code)R02 A Ll(D 1 <br /> Mailing Address, City, St.,Zipt t}21 t C 2. <br /> ACTUAL WELL LOCATION: County i-tt�� <br /> Property Address, City, St,Zip LA0ZVA1kya' -A, Ctanc�n C- %-1.CQ. �SI ZM <br /> 1/4 of the 1/4,Sec. ,Twp. ®N. or 13 S.,Range 13 E.or ® W., P.M. <br /> Distance from Section Lines Ft.from 0 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, zonep12� or zone 13 n; Units must be meters; Datum must be NAD83;Unit must beset to true north. <br /> Fasting �Q 56?�/r q Northing j U `T <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 /> 0 The well was not in use and was plugged and sealed. <br /> Other(please explain)L-YA-,oaxor o rx ci%LQ.V%t A4,. - <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 /> p`JO 110 31s 4=xQ&ik ho k,,Qkv !, x 2 h, gs)\- a .4. Du r. Q,�k from feet to feet <br /> L 01 b M�xuA 4 c ra caoQ,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 or ter full name If signing print name&title Date(mm/dd/yyyyy) <br /> It is t r sibilit of th owner to have the well/hole properly plugged and sealed. The Well Construction Contractor <br /> is responsible for no ina the owner of this reouirement. <br />