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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 fi)::ZE /L, -32 <br /> Individual/Company responsible for plugging and sealing the well: <br /> Name(s) Gogl 82 1 k ttn!; L-LC—- <br /> Mailing AddressZlM- <br /> City,St.,Zip �kbak %(a., CO- gl tAO') <br /> Phone(area code&no.)dllD• 2-1 S-1 1'%Email: YXQrX& c�o ,cow <br /> Well (Hole)Owner: ��`` � <br /> NAME(S) 2-��wl 1'U \g Phone(include area code) tv — A\8"1 <br /> Mailing Address, City, St.,Zip b �q`a S Z <br /> ACTUAL WELL LOCATION: County CtL (�- <br /> Property Address,City, St,Zip Lk 2. c. '1 S\2-1 <br /> 1/4 of the 1/4,Sec. ,Twp. ❑N.or 0 S.,Range ® E.or 0 W., P.M. <br /> Distance from Section Lines Ft.from n N.or C3 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, zofn�e�12 C1 or zone 13 H; Units must be meters; Datum must be NAD83;Unit must be set to true north. <br /> Easting l 6) 5 5 7 /.3 Northing /R 0 Z. P)-1 --�. <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 /> WEI he well was not in use and was plugged and sealed. <br /> Other(please explain)1✓X�� OC\ GOtLQ.�fW1Q. <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 /> SO k1a 3/R )-Qc' 'yu. X 3 "dabkdl d D1,111AOow from _feet to !7 feet <br /> 91Ctb C¢.f•' ZA-V ratxa coo; �n,c1 from feet to 5 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 /> It i �he�ren;si it a well owner to have the well/hole proper y plugged and sealed. The Well Construction Contractor <br /> is reor notifying the owner of this requirement. <br />