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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 (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 K.M LT-7 <br /> Individual/Company``responsible for plugging and sealing the well: 1 <br /> NAME(S) 1WSJ t 1iA jj:jjVF 1 y",cjjaeJL <br /> Cc l n <br /> Mailing Address �04� fA L V- TV�� S <br /> City,St.,Zip —11& � �3 <br /> Phone (��U ) Z`( - <br /> Well(Hole)Owner: <br /> (�i�r� n 2 <br /> NAME lS) olnvcA()r) • Ic)�c z«� I Phone ( �t TV ) 9� <br /> Mailing Address,City,St.,Zip —p O �hnY �� sr iyPllny� C d <br /> i <br /> ACTUAL WELL LOCATION: County ,h Tt uv\ <br /> Property Address,City,St,Zip <br /> 1/4 of the 1/4,Sec._,Twp. ❑ N.or❑S.,Range ❑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: <br /> Format must be UTM, zone 12 ❑ or zone 13A. Units must be meters;Datum must be NAD83; Unit must be set to true north. <br /> Easting Northing 4-11127 G,3 to <br /> I(we)report the existing well(hole)was plugged and sealed on the date of Z� 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) -r SP4 '� <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 /> from feet to ZU feet <br /> I Uvt�Of C4 I C Q AA 1/1cJl��'U(CV from �� feet to�_feet <br /> IM iAIA S ►,ta on -e GIU Q V u A <br /> y�ou ` I <br /> o ta► � f►+n Slavn, -�t•tunwti P_ tuLP from 1 Meet to S�tV Pfeet <br /> Intervals of casing removed/ripped In feet V� IC, 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 /> i <br /> Signatur Please print the Signer's Name&Title Date <br /> It is the responsibility 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 />