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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 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 f�7�, - to -30 <br /> Individual/Company responsible for plugging and sealing the well: <br /> Name(s) laDJ rot, -D&1 t" LLC- <br /> Mailing Address W3EQ SA. 1 <br /> City,St.,Zip % vC�(u %Q., LU. e)14D-5 <br /> Phone(area code&no.)TId- Email: 0�Bqc to - co <br /> Well(Hole)Owner: ff ,,'' ''1`-i NAME(S�� �2. 1� llafk*ks Phone(include area code)�` &-'q1$0I <br /> Mailing Address, City, St.,Zip ��� v0 5°1 t 6i�cA1R � 6 Ynp60. V tq 2 <br /> ACTUAL WELL LOCATION: County ( ic'ah%x >T _ <br /> Property Address, City, St,Zipg0?_ V1A11WECI UW22, �� � �• $I212 <br /> 1/4 of the 1/4,Sec. ,Twp. ®N.or 0 S., Range ® E.or [3 W., P.M. <br /> Distance from Section Lines Ft.from n N.or E] 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 12 171 or zone 13 151; Units must be meters; Datum must be NAD83;Unit must be set to true north. <br /> Easting S6- —7 Northing /X6'3 j '� ?• <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 /> ❑The well was not in use and was plugged and sealed. <br /> Other(please explain) 6WID`Of1Wany-, Ct>(LQ, Y Okt, <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 /> �b 3 j9, �W&20 4 d '[�k3uu tnA from _feet to feet <br /> ut)o CA.ow"+ cL cninvi L� from O 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 or enter full name If signing print name&title Date(mm/dd/yyyyy) <br /> It is th re risibility e I 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 />