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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 /> 5/2011 i (303)866-3581 Fax(303)866-3589 http•//www.water.state.co.us <br /> WELL ABANDONMENT REPORT <br /> Use to report plugging and sealing of permitted wells,monitoring and other holes. Type or <br /> print in black or blue ink. Instructions and plugging standards are on reverse side of form. <br /> Well Permit Number of the well being plugged or <br /> MH File Number MH- Hole ID#/Name — <br /> Individual/Company responsible for plugging ansealing I the well: 1 <br /> NAME(S) Tr4AA1uj& �f Imo}} <br /> Mailing Address b 4 } �e_c,k -f'A AX V- DO?L ?_ <br /> City,St.,Zip nn� <br /> Phone (q7y ) <br /> Well(Hole)Owner: <br /> NAME(S) o�VV�U C--)o(c)tbetc)� :1A 1 Phone ( 70 ) G�G- C12A'S <br /> Mailing Address,City,St.,Zip <br /> ACTUAL WELL LOCATION: County SGw1 1'• <br /> Property Address,City,St,Zip <br /> 1/4 of the_1/4,Sec._,Twp. N.or 0 S.,Range p E.or(]W.,—P.M. <br /> Distance from Section Lines Ft.From ❑ N.or❑ 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: j <br /> Format must be UTM, zone 12 or zone 13. Units must be meters;Datum must be NAD83; Unit must be set to true north. <br /> Easting 24 3 3 S 1. Northing 419 A-�27, �'Z <br /> I(we)report the existing well(hole)was plugged and sealed on the date of � GT_� 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) 'juQq!ES e V' VVA 4214+ w —— <br /> TT ywy <br /> The well was plugged with the following materials placed at the indicated intervals: l' <br /> Amount and Type of Material + Meth of Placement Interval <br /> T.> 1��niVlct_ C.Uec) Auyi►Au uc{1/ kliT��� '1i�1` from�5 feet to �I s _feet <br /> v <br /> �Vn«( t1)nLLM— �j from feet to�_feet <br /> e _�(+ W from. Q feet to Meet <br /> Intervals of casing removed/ripped in feet from feet to feet <br /> Report must be signed by person who performed the well plugging work or by the well owner if this person is unknown or not reachable. I <br /> (we)hav read the statements made herein,know the contents thereof,and that they are true to my(our)knowledge. <br /> Signatu s) Please print the Signer's Name&Title Date <br /> -------------- <br /> It is the r4sponsibility of the well owner to have the well/hole properly plugged and sealed. The Well Construction Contractor <br /> is responsible for notifying the owner of this requirement. <br />