Laserfiche WebLink
x <br /> 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 /> 5/201 I (303)866-3581 Fax(303)866-3589 htttp://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,A C f- <br /> Individual/Company responsible for plugging and sealing the well: <br /> NAME(S) <br /> Mailing Address Eel <br /> go <br /> Chu+-P.r` �hri►,P <br /> City,St.,Zip <br /> Phone ( �74_) ) _Lca- OG� ----- <br /> Well(Hole)Owner: !! rr t qq <br /> NAME(S) CC,1 �0 Phone <br /> Mailing Address,City,St.,Zip t7 0 Rox Si l uctr iA C 0 E 14- __ <br /> ACTUAL WELL LOCATION: County C-Z,,A ^ r. v <br /> Property Address,City,St,Zip <br /> 1/4 of the 114,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 13X; Units must be meters;Datum must be NAD83; Unit must be set to true north. <br /> Fasting (m 3'77, 69 Northing A("i 7 I �01�. l E <br /> I(we)report the existing well (hole)was plugged and sealed on the date of 102 I ` 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) f <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 /> AAA a_/ ui ct�P V- from (0 Q feet to _feet <br /> it C� l from feet to��_feet <br /> t-I X tw wu r <br /> 1peMuA j f' from feet toy` �r Pfeet <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. <br /> (we)have read the statements made herein,know the contents thereof,and that they are true to my(our)knowledge. <br /> 7r, <br /> ) _ Please printthe Signer's Name&Title j� Date <br /> �.-{- <br /> C -,� d4 <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 />