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Form No. I STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only <br /> GWS-09 1821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br /> 5/201 t (303)866-3581 Fax(303)866-3589 http://www wate[.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 ' T 6 <br /> Individual/ComDeny responsible for oluoging and sealing the well: <br /> NAME(S) n-A 7y 0f ��ILi;t�h�✓' 'LPc� ! <br /> ff ') <br /> Mailing Address b�� 7N `eAA:CV- <br /> City,St.,Zip LQ R 1,30 1 <br /> Phone <br /> Well(Hole)Owner: <br /> NAME(S) 06 CAO-D 60 le @-& • MAL Phone <br /> Mailing Address, City,St.,Zip C' y3-x �&Jtx'd+" Co ' . Dj I49-0 - <br /> ACTUAL WELL LOCATION: County v) .j;,ac,v1 <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 13 X Units must be meters;Datum must be NAD83; Unit must be set to true north. <br /> Easting jo':7 Northing 1Q S r j S• c t <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) 1 <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 /> �^ n - "�� V�'Jlf!It n from 3 feet to H 1 h feet <br /> it c t, V �'��f�i t�CJ CJWJYk,' i <br /> 1�_ from — feet to feet <br /> �AIX ' W t% <br /> Vn SuMN -�Y.A>MW i� '�t,t�1 from 1_feet to , feet <br /> Intervals of casing removed/ripped in feet A J p1 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)have 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 /> 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 />