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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 1 (303)866-3581 Fax (303)866-3589 htto://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 and sealing the well: <br /> NAME(S) ITQAa �Vt -T1�V'a ,tPr AlAf.'V' &-C,'�-eCJA <br /> Mailing Address (.4G *TeC� C4?AA-e�- birI v e <br /> City,St.,Zips l <br /> Phone <br /> Well(Hole)Owner: i 1 ((,,��,,.,, A <br /> NAME(S)��� l/���j tt lcl Phone (1�L) QT6 -9 4S <br /> Mailing Address,City,St.,Zip <br /> ACTUAL WELL LOCATION: County ,�{in lUU16 <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 O or zone 13g, Units must be meters;Datum must be NAD83; Unit must beset to true north. <br /> A L <br /> _E_asting CA_ ^ . �V Northing S L � (0 <br /> I(we)report the existing well(hole)was plugged and sealed on the date off 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) C U 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 /> from (oQ feet to C�feet <br /> P -�nv�m �feet to l0' _feet <br /> 4S t>� Pp,�t y� 1 �avKlt to wy � ���Mf� �� � from feet to Sc� u et <br /> '�` i r in �n� Q �o J w� Sluvv� <br /> Intervals of casing removedfripped in feet 4A (C� 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 /> Signature( Please print the Signer's Name&Title Date <br /> �oltic.�ctt/l�c-�V <br /> It is there ponsibility 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 /> t <br />