Laserfiche WebLink
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 dwrpermitsonlineOstate.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 67 -UP -3 <br /> Individual/Co <br /> mpany responsible for plugging and sealing the well: <br /> Name(s) <br /> Mailing Address &Z SD Z U�►r�, gat!, <br /> City,St.,Zip Mn 1'W's <br /> Phone(area code&no.)77a Z- 7 5-/'758 Email: 01e J rb aw/ <br /> Well(Hole)Owner: <br /> NAME(S) Zhu a l A tAA. S Phone(include area code) <br /> Mailing Address, City, St.,Zip 3 2— <br /> ACTUAL WELL LOCATION: Countyt�tn�r. <br /> Property Address,City, St,Zi or% CD- 8 212 <br /> 1/4 of the 1/4,Sec. ,Twp. E3 N.or Ell S., Range ® E.or ® W., P.M. <br /> Distance from Section Lines Ft.from r N.or S., Ft.from ®E. or [3W.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 12 171 or zone 13 r7l; Units must be meters; Datum must be NAD83; Unit must be set to true north. <br /> Easting ® 5" Northing ,�2 D 2 (4 3 3, <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 /> E3 The well was not in use and was plugged and sealed. <br /> Other(please explain) E_XTn�orl R on am t. ��ktZ <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 /> 3/e flog �A dJtvpkd qv'- ¢ from�_feet to feet <br /> from 'C) feet to S 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 orenter full nnaamen If signing print name&title Date(mm/dd/yyyyy) <br /> C L <br /> It i he res 1 ili owner to have the well/hole properly plu ged and sealed. The Well Construction Contractor <br /> is re sible for notifyinq the owner of this requirement. <br />